KIMTEK transport units fit Can-Am Defender and Can-Am Defender Max

MEDLITE® and FIRELITE® slip-on skid units do the job in Can-Am side-by-sides ORLEANS, Vt. — KIMTEK Corp, makers of MEDLITE® and FIRELITE® Transport skid units for off-road rescue and wildland firefighting, announce the full compatibility of their top-selling line of UTV-based skid units with Can-Am Defender and Can-Am Defender Max (crew) side-by-side UTVs. The Defender's rugged ...

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Full Time Faculty/Clinical Coordinator Position in Emergency - MassBay Community College

Position Summary MassBay Community College seeks a qualified full time instructor for the Emergency Medical Services Department. The EMS faculty member teaches courses in the classroom, skills and simulation laboratory, and in clinical setting in the EMT and Paramedicine Programs. This instructor also serves as Clinical Coordinator to advocate for clinical and field placements, will monitor student ...

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EMCrit – Some Weeish Elaboration on my Interview with the Curbsiders

Why can't we all just get along

EMCrit by Scott Weingart.

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EMCrit – Some Weeish Elaboration on my Interview with the Curbsiders

Why can't we all just get along

EMCrit by Scott Weingart.

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Training and Development Specialist - Ready Responders

The Role The Training and Development Specialist (TDS) is responsible for designing and implementing the training programs for all Ready Responders teammates: onboarding, new industry standards, reinforcement of best practices, targeted trainings to address gaps, seasonal trainings, etc. While Ready Responders start their roles with foundational knowledge and experience, the TDS has the unique opportunity ...

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Supply Chain Manager - Ready Responders

About The Role The Supply Chain Manager will work closely with the Chief Operations Officer and Team Supervisors to drive and manage company-wide processes, ensuring that every Ready Responder is able to provide the highest level of care to patients across Orleans Parish. Each Ready Responder will be equipped with his/her own kit of essential tools and equipment so that (s)he is fully prepared for every ...

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Supervisor - Ready Responders

The Role As a Ready Responders Supervisor you will directly manage and provide ongoing support to Ready Responders: regular individual check-ins, troubleshooting as needed, general and targeted performance management, and ongoing coaching and support. This integral role will not only be responsible for maintaining the overall performance of his/her Responder team, (s)he will hold a high bar for both ...

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Paramedic - Ready Responders

About The Role When you join our team as a Ready Responder, you will join a group of dedicated healthcare providers who are licensed, trained, and credentialed to respond at the EMT-Basic level of care. Our Responders provide two types of service: Acute care response, high priority calls for service Help to improve patient outcomes by arriving at the scene within minutes Provide on-scene triage and ...

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Emergency Medical Technician - Ready Responders

About The Role When you join our team as a Ready Responder, you will join a group of dedicated healthcare providers who are licensed, trained, and credentialed to respond at the EMT-Basic level of care. Our Responders provide two types of service: Acute care response, high priority calls for service Help to improve patient outcomes by arriving at the scene within minutes Provide on-scene triage and ...

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Paramedic--Flexible Hours - Ready Responders

About The Role When you join our team as a Ready Responder, you will join a group of dedicated healthcare providers who are licensed, trained, and credentialed to respond at the EMT-Basic level of care. Our Responders provide two types of service: Acute care response, high priority calls for service Help to improve patient outcomes by arriving at the scene within minutes Provide on-scene triage and ...

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EMT--Flexible Hours - Ready Responders

About The Role When you join our team as a Ready Responder, you will join a group of dedicated healthcare providers who are licensed, trained, and credentialed to respond at the EMT-Basic level of care. Our Responders provide two types of service: Acute care response, high priority calls for service Help to improve patient outcomes by arriving at the scene within minutes Provide on-scene triage and ...

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EEMCrit Resident Competition 2018

APPLY NOW: 2018 Essentials of Emergency Medicine Education Fellowship Program and Essentials of EMCrit BLAST Competition The Essentials of Emergency Medicine (EEM) conference is in May 2018, but opportunities for residents start NOW. EEM is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are […]

EMCrit by Scott Weingart.

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EEMCrit Resident Competition 2018

APPLY NOW: 2018 Essentials of Emergency Medicine Education Fellowship Program and Essentials of EMCrit BLAST Competition The Essentials of Emergency Medicine (EEM) conference is in May 2018, but opportunities for residents start NOW. EEM is one of the largest live EM educational conferences in the world with over 2,000 attendees. The conference organizers, led by Dr. Paul Jhun, are […]

EMCrit by Scott Weingart.

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Patient-Centered Structured Interdisciplinary Bedside Rounds in the Medical ICU

Objectives: We examined the effects of introducing patient-centered structured interdisciplinary bedside rounds in the medical ICU with respect to rounding efficiency, provider satisfaction, and patient/family satisfaction. Design: A prospective, nonblinded, nonrandomized, parallel group study from June 21, 2016, to August 15, 2016. Setting: The medical ICU at a tertiary care academic medical center. Subjects: A consecutive sample of adult patients, family members, and healthcare providers. The patients and healthcare providers were arbitrarily assigned to either the patient-centered structured interdisciplinary bedside rounds or nonstructured interdisciplinary bedside round care team. Interventions: Healthcare providers on the patient-centered structured interdisciplinary bedside rounds team were educated about their respective roles and the information they were expected to discuss on rounds each day. Rounds completion data and satisfaction questionnaires from healthcare providers, patients, and family members were obtained from both patient-centered structured interdisciplinary bedside rounds and nonstructured interdisciplinary bedside round teams. Measurements and Main Results: Data were obtained from 367 patient-centered structured interdisciplinary bedside rounds and 298 nonstructured interdisciplinary bedside round patient encounters. Family members were present during 31.1% rounding encounters on the patient-centered structured interdisciplinary bedside rounds team and 10.1% encounters on the nonstructured interdisciplinary bedside round team (p

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NLRP3 Inflammasome Activation Contributes to Mechanical Stretch–Induced Endothelial-Mesenchymal Transition and Pulmonary Fibrosis

Objectives: Mechanical ventilation can induce lung fibrosis. This study aimed to investigate whether ventilator-induced lung fibrosis was associated with endothelial-mesenchymal transition and to uncover the underlying mechanisms. Design: Randomized, controlled animal study and cell culture study. Setting: University research laboratory. Subjects: Adult male Institute of Cancer Research, NACHT, LRR, and PYD domains-containing protein 3 (NLRP3) knockout and wild-type mice. Primary cultured mouse lung vascular endothelial cells. Interventions: Institute of Cancer Research, NLRP3 knockout and wild-type mice were subjected to mechanical ventilation (20 mL/kg) for 2 hours. Mouse lung vascular endothelial cells were subjected to cyclic stretch for 24 hours. Measurements and Main Results: Mice subjected to mechanical ventilation exhibited increases in collagen deposition, hydroxyproline and type I collagen contents, and transforming growth factor-β1 in lung tissues. Ventilation-induced lung fibrosis was associated with increased expression of mesenchymal markers (α smooth muscle actin and vimentin), as well as decreased expression of endothelial markers (vascular endothelial–cadherin and CD31). Double immunofluorescence staining showed the colocalization of CD31/α smooth muscle actin, CD31/vimentin, and CD31/fibroblast-specific protein-1 in lung tissues, indicating endothelial-mesenchymal transition formation. Mechanical ventilation also induced NLRP3 inflammasome activation in lung tissues. In vitro direct mechanical stretch of primary mouse lung vascular endothelial cells resulted in similar NLRP3 activation and endothelial-mesenchymal transition formation, which were prevented by NLRP3 knockdown. Furthermore, mechanical stretch–induced endothelial-mesenchymal transition and pulmonary fibrosis were ameliorated in NLRP3-deficient mice as compared to wild-type littermates. Conclusions: Mechanical stretch may promote endothelial-mesenchymal transition and pulmonary fibrosis through a NLRP3-dependent pathway. The inhibition of endothelial-mesenchymal transition by NLRP3 inactivation may be a viable therapeutic strategy against pulmonary fibrosis associated with mechanical ventilation. Drs. Lv, Wang, and Liu contributed equally to this work and should be considered as cofirst authors. Supported, in part, by grants from Shanghai Municipal Commission of Health and Family Planning to Dr. Jiang (No. 2017BR062) and from the National Natural Science Foundation of China to Dr. Jiang (Number 81772117, Number 81571929, Number 81272144), Dr. Zhu (Number 31671213, Number 31271270), Dr. Mao (Number 81372100), and Dr. Liu (Number 81672266, Number 31371164). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Drs. Liu and Zhu received support for article research from the National Natural Science Foundation of China. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Dr. Xiao-Yan Zhu, PhD, Department of Physiology, Second Military Medical University, 800 Xiangyin Road, Shanghai 200433, China. E-mail: xiaoyanzhu@smmu.edu.cn; or Dr. Lai Jiang, PhD, Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China. E-mail: jianglai@xinhuamed.com.cn Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Informed Consent Documents Used in Critical Care Trials Often Do Not Implement Recommendations

Objective: Informed consent documents are often poorly understood by research participants. In critical care, issues such as time pressure, patient capacity, and surrogate decision making complicate the consent process further. Recommendations exist for addressing critical care–specific consent issues; we examined how well existing practice implements these recommendations. Design: We conducted a systematic search of the literature for recommendations specific to critical care informed consent and rated existing informed consent documents on their implementation of 1) 18 of these critical care recommendations and 2) 36 previously developed general informed consent recommendations. Four hundred twelve registered critical care trials were identified and a request sent to the principal investigators for an example of the informed consent document associated with the trial. Each consent document was rated on both set of recommendations. Setting: We evaluated informed consent documents for trials conducted in English or French registered with clinicaltrials.gov. Patients: Not applicable. Interventions: Not applicable. Measurements and Main Results: Independent coders rated implementation of each recommendation on a four-point scale. Of 412 requests, 137 informed consent documents were returned, for a response rate of 34.1%. Of these, 86 met inclusion criteria and were assessed. Overall agreement between raters was 90.6% (weighted κ = 0.79; 0.77–0.81). Implementation of the 18 critical care recommendations was highly variable, ranging between 2% and 96.5%. Conclusions: Critical care studies often do not provide the information recommended for those providing consent for research. These clear recommendations provide testable hypotheses about how to improve the consent process for patients and family members considering trial participation in the critical care setting. This study was approved by the Ottawa Health Science Network Research Ethics Board. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Supported, in part, by the Canadian Institutes of Health Research Open Operating Grants Program 130354. Dr. Brehaut has disclosed that partial funding from a related grant (Canadian Institutes of Health Research) supported some of the submitted work. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jbrehaut@ohri.ca Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Renal Replacement Therapy Modality in the ICU and Renal Recovery at Hospital Discharge

Objectives: Acute kidney injury requiring renal replacement therapy is a major concern in ICUs. Initial renal replacement therapy modality, continuous renal replacement therapy or intermittent hemodialysis, may impact renal recovery. The aim of this study was to assess the influence of initial renal replacement therapy modality on renal recovery at hospital discharge. Design: Retrospective cohort study of all ICU stays from January 1, 2010, to December 31, 2013, with a “renal replacement therapy for acute kidney injury” code using the French hospital discharge database. Setting: Two hundred ninety-one ICUs in France. Patients: A total of 1,031,120 stays: 58,635 with renal replacement therapy for acute kidney injury and 25,750 included in the main analysis. Interventions: None. Measurements Main Results : PPatients alive at hospital discharge were grouped according to initial modality (continuous renal replacement therapy or intermittent hemodialysis) and included in the main analysis to identify predictors of renal recovery. Renal recovery was defined as greater than 3 days without renal replacement therapy before hospital discharge. The main analysis was a hierarchical logistic regression analysis including patient demographics, comorbidities, and severity variables, as well as center characteristics. Three sensitivity analyses were performed. Overall mortality was 56.1%, and overall renal recovery was 86.2%. Intermittent hemodialysis was associated with a lower likelihood of recovery at hospital discharge; odds ratio, 0.910 (95% CI, 0.834–0.992) p value equals to 0.0327. Results were consistent across all sensitivity analyses with odds/hazards ratios ranging from 0.883 to 0.958. Conclusions: In this large retrospective study, intermittent hemodialysis as an initial modality was associated with lower renal recovery at hospital discharge among patients with acute kidney injury, although the difference seems somewhat clinically limited. A complet list of board members of the AzuRéa Group is as follows: Pierre-François Perrigault, Matthieu Jabaudon, Bernard Allaouchiche, Marc Leone, Jean-Christophe Orban, Matthieu Legrand, Sébastien Perbet, Claire Roger, Jean-Michel Julia, Serge Molliex, Russell Chabanne, François Antonini, Sophie Kauffmann, Pierre-Eric Danin, Thomas Godet, Olivier Langeron, Arnaud Friggeri, Thomas Geeraerts, Laurent Muller, Jacques Ripart, Olivier Baldesi, Saber Barbar, Jérôme Morel, Alain Lepape, Pierre-Marie Bertrand, Jean-Etienne Bazin, Ali Mofredj, Béatrice Riu-Poulenc, Karim Lakhal, Vincent Minville, Emmanuel Futier Philippe Guerci, Emmanuel Novy, Pierre Bouzat, Qin Lu, and Karim Debbat. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Dr. Bonnassieux disclosed that the study received financial support from Gambro-Hospal-Baxter, however, Gambro-Hospal-Baxter had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article. Dr. Schneider’s institution received funding from Gambro-Hospal-Baxter, Fresenius Medical Care, and BBraun Avitum. Drs. Schmidt, Bénard, Cancalon’s, and Ichai institutions received funding from Gambro-Hospal-Baxter. Dr. Joannes-Boyau’s institution received funding from Asahi Kasei, and he received funding from Gambro-Hospal-Baxter, BBraun, Merck Sharp and Dohme, and Fresenius Medical Care. Dr. Constantin has received consulting fees or speaker honorarium from Gambro-Hospal-Baxter. Dr. Kellum received funding from Baxter and NxStage. Dr. Rimmelé received consulting fees or speaker honorarium from Gambro-Hospal-Baxter and Fresenius Medical Care. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: martin.bonnassieux@chu-lyon.fr Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Urinary Oxygenation as a Surrogate Measure of Medullary Oxygenation During Angiotensin II Therapy in Septic Acute Kidney Injury

Objectives: Angiotensin II is an emerging therapy for septic acute kidney injury, but it is unknown if its vasoconstrictor action induces renal hypoxia. We therefore examined the effects of angiotensin II on intrarenal PO2 in ovine sepsis. We also assessed the validity of urinary PO2 as a surrogate measure of medullary PO2. Design: Interventional study. Setting: Research Institute. Subjects: Sixteen adult Merino ewes (n = 8/group). Interventions: Sheep were instrumented with fiber-optic probes in the renal cortex, medulla, and within a bladder catheter to measure PO2. Conscious sheep were infused with Escherichia coli for 32 hours. At 24–30 hours, angiotensin II (0.5–33.0 ng/kg/min) or saline vehicle was infused. Measurements and Main Results: Septic acute kidney injury was characterized by hypotension and a 60% ± 6% decrease in creatinine clearance. During sepsis, medullary PO2 decreased from 36 ± 1 to 30 ± 3 mm Hg after 1 hour and to 20 ± 2 mm Hg after 24 hours; at these times, urinary PO2 was 42 ± 2, 34 ± 2, and 23 ± 2 mm Hg. Increases in urinary neutrophil gelatinase-associated lipocalin (12% ± 3%) and serum creatinine (60% ± 23%) were only detected at 8 and 24 hours, respectively. IV infusion of angiotensin II, at 24 hours of sepsis, restored arterial pressure and improved creatinine clearance, while not exacerbating medullary or urinary hypoxia. Conclusions: In septic acute kidney injury, renal medullary and urinary hypoxia developed several hours before increases in currently used biomarkers. Angiotensin II transiently improved renal function without worsening medullary hypoxia. In septic acute kidney injury, angiotensin II appears to be a safe, effective therapy, and urinary PO2 may be used to detect medullary hypoxia. Supported, in part, by grants from the National Health and Medical Research Council of Australia (1050672) and by funding from the Victorian Government Operational Infrastructure Support Grant and the Jack Brockhoff Foundation (ID 4178). Dr. Lankadeva’s institution received funding from a Jack Brockhoff Foundation Early Career Medical Research Grant and was supported by Postdoctoral Fellowship from the National Heart Foundation of Australia (NHF, 100869). Dr. Evans’ institution received funding from National Health and Medical Research Council of Australia. Dr. May’s institution received funding from National Health and Medical Research Council of Australia, National Heart Foundation of Australia, and the Jack Brockhoff Foundation, and he received other support from a Victorian Government Operational Infrastructure Support Grant. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: clive.may@florey.edu.au Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Perceptions of Risk and Safety in the ICU: A Qualitative Study of Cognitive Processes Relating to Staffing

Objectives: The aims of this study were to 1) examine individual professionals’ perceptions of staffing risks and safe staffing in intensive care and 2) identify and examine the cognitive processes that underlie these perceptions. Design: Qualitative case study methodology with nurses, doctors, and physiotherapists. Setting: Three mixed medical and surgical adult ICUs, each on a separate hospital site within a 1,200-bed academic, tertiary London hospital group. Subjects: Forty-four ICU team members of diverse professional backgrounds and seniority. Interventions: None. Main Results: Four themes (individual, team, unit, and organizational) were identified. Individual care provision was influenced by the pragmatist versus perfectionist stance of individuals and team dynamics by the concept of an “A” team and interdisciplinary tensions. Perceptions of safety hinged around the importance of achieving a “dynamic balance” influenced by the burden of prevailing circumstances and the clinical status of patients. Organizationally, professionals’ risk perceptions affected their willingness to take personal responsibility for interactions beyond the unit. Conclusions: This study drew on cognitive research, specifically theories of cognitive dissonance, psychological safety, and situational awareness to explain how professionals’ cognitive processes impacted on ICU behaviors. Our results may have implications for relationships, management, and leadership in ICU. First, patient care delivery may be affected by professionals’ perfectionist or pragmatic approach. Perfectionists’ team role may be compromised and they may experience cognitive dissonance and subsequent isolation/stress. Second, psychological safety in a team may be improved within the confines of a perceived “A” team but diminished by interdisciplinary tensions. Third, counter intuitively, higher “situational” awareness for some individuals increased their stress and anxiety. Finally, our results suggest that professionals have varying concepts of where their personal responsibility to minimize risk begins and ends, which we have termed “risk horizons” and that these horizons may affect their behavior both within and beyond the unit. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Drs. D’Lima and Murray share joint first authorship. Dr. D’Lima contributed in thematic structure and analysis, writing of first draft, writing of final draft, revision of articles, and approval of final draft; Dr. Murray contributed in original concept and study design, collection of data, thematic structure, writing of first draft and final draft, revision of articles, and approval of final draft; Dr. Brett contributed in original concept and study design, review of emerging themes, revision of articles, and approval of final draft. The views expressed are those of the authors and not necessarily those of The Health Foundation, National Institute for Health Research, the NHS or the Department of Health. Supported, in part, by the National Institute for Health Research comprehensive Biomedical Research Centre, the Patient Safety Translational Research Centre based at Imperial College Healthcare National Health Service Trust and Imperial College London, and The Health Foundation. Dr. Murray’s institution received funding from The Health Foundation. Dr. Brett’s institution received funding from The Health Foundation, and he received other support from the National Institute for Health Research Comprehensive Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London (general support for research). Dr. D’Lima disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: eleanor.murray@sbs.ox.ac.uk Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Influence of Postoperative Thrombosis Prophylaxis on the Recurrence of Chronic Subdural Hematoma After Burr-Hole Drainage

Objectives: Chronic subdural hematoma is a commonly encountered disease in neurosurgic practice, whereas its increasing prevalence is compatible with the ageing population. Recommendations concerning postoperative thrombosis prophylaxis after burr-hole drainage of chronic subdural hematoma are lacking. The aim of this study was to analyze the correlation between recurrence of chronic subdural hematoma and postoperative application of thrombosis prophylaxis. Design: Retrospective, consecutive sample of patients undergoing burr-hole drainage for chronic subdural hematoma over 3 years. Setting: Single, academic medical center. Patients: All patients undergoing surgical evacuation of a chronic subdural hematoma with burr-hole drainage. Exclusionpatients under the age of 18 years, who presented with an acute subdural hematoma and those who underwent a craniotomy. Interventions: We compared patients receiving thrombosis prophylaxis treatment after burr-hole drainage of chronic subdural hematoma with those who were not treated. Primary outcome measure was reoperation of chronic subdural hematoma due to recurrence. Secondary outcome measures were thromboembolic and cardiovascular events, hematologic findings, morbidity, and mortality. In addition, a subanalysis comparing recurrence rate dependent on the application time of thrombosis prophylaxis ( 48 hr) was undertaken. Measurements and Main Results: Overall recurrence rate of chronic subdural hematoma was 12.7%. Out of the 234 analyzed patients, 135 (57.3%) received postoperative thrombosis prophylaxis (low-molecular-weight heparin) applied subcutaneously. Recurrence of chronic subdural hematoma occurred in the thrombosis prophylaxis group and control group in 12 patients (8.9%) and 17 patients (17.2%), respectively, showing no significant difference (odds ratio, 0.47 [95% CI, 0.21 – 1.04]). A subanalysis comparing recurrence rate of chronic subdural hematoma dependent on the application time of thrombosis prophylaxis ( 48 hr) showed no significant difference either (odds ratio, 2.80 [95% CI, 0.83–9.36]). Higher dosage of thrombosis prophylaxis correlated with recurrence rates of chronic subdural hematoma, both in univariate and multivariate analyses. Conclusions: Our data suggest that the application of postoperative thrombosis prophylaxis after burr-hole drainage for chronic subdural hematoma does not result in higher recurrence rates of chronic subdural hematoma. In addition, it seems that early administration of thrombosis prophylaxis (

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Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis

Objectives: The objective of this systematic review and meta-analysis was to assess acute kidney injury with combination therapy of vancomycin plus piperacillin-tazobactam, in general, adult patients and in critically ill adults. Rates of acute kidney injury, time to acute kidney injury, and odds of acute kidney injury were compared with vancomycin monotherapy, vancomycin plus cefepime or carbapenem, or piperacillin-tazobactam monotherapy. Data Sources: Studies were identified by searching Pubmed, Embase, Web of Science, and Cochrane from inception to April 2017. Abstracts from selected conference proceedings were manually searched. Study Selection: Articles not in English, pediatric studies, and case reports were excluded. Data Extraction: Two authors independently extracted data on study methods, rates of acute kidney injury, and time to acute kidney injury. Effect estimates and 95% CIs were calculated using the random effects model in RevMan 5.3. Data Synthesis: Literature search identified 15 published studies and 17 conference abstracts with at least 24,799 patients. The overall occurrence rate of acute kidney injury was 16.7%, with 22.2% for vancomycin plus piperacillin-tazobactam and 12.9% for comparators. This yielded an overall number needed to harm of 11. Time to acute kidney injury was faster for vancomycin plus piperacillin-tazobactam than vancomycin plus cefepime or carbapenem, but not significantly (mean difference, –1.30; 95% CI, –3.00 to 0.41 d). The odds of acute kidney injury with vancomycin plus piperacillin-tazobactam were increased versus vancomycin monotherapy (odds ratio, 3.40; 95% CI, 2.57–4.50), versus vancomycin plus cefepime or carbapenem (odds ratio, 2.68; 95% CI, 1.83–3.91), and versus piperacillin-tazobactam monotherapy (odds ratio, 2.70; 95% CI, 1.97–3.69). In a small subanalysis of 968 critically ill patients, the odds of acute kidney injury were increased versus vancomycin monotherapy (odds ratio, 9.62; 95% CI, 4.48–20.68), but not significantly different for vancomycin plus cefepime or carbapenem (odds ratio, 1.43; 95% CI, 0.83–2.47) or piperacillin-tazobactam monotherapy (odds ratio, 1.35; 95% CI, 0.86–2.11). Conclusions: The combination of vancomycin plus piperacillin-tazobactam increased the odds of acute kidney injury over vancomycin monotherapy, vancomycin plus cefepime or carbapenem, and piperacillin-tazobactam monotherapy. Limited data in critically ill patients suggest the odds of acute kidney injury are increased versus vancomycin monotherapy, and mitigated versus the other comparators. Further research in the critically ill population is needed. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). Drs. Luther, Timbrook, and Dosa disclosed government work. Dr. Luther received other support from Pfizer, Cubist (Merck) research funding, and the Office of Academic Affiliations (VA) fellowship. Dr. Timbrook received other support from VA Office of Academic Affiliations fellowship, Biofire Diagnostics, GenMark Diagnostics, speaker and/or consultancy. Dr. Caffrey’s institution received funding from Pfizer, Merck, and the Medicines Company. Dr. Lodise received funding from Cubist (Merck), the Medicines Company, research funding, speaker, and/or consultancy. Dr. LaPlante received other funding from Pfizer, Cubist (Merck), Forest (Allergan), The Medicines Company, and Melinta research funding, speaker, and/or consultancy. The work was supported, in part, by resources and use of facilities at the Providence Veterans Affairs Medical Center. Presented, in part, as a poster (Number 1805) at IDweek 2016, New Orleans, LA, October 29, 2016. The contents do not represent the views of the U.S. Department of Veterans Affairs or the U.S. government. For information regarding this article, E-mail: megankluther@gmail.com Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Use of intrathoracic pressure regulation therapy in breathing patients for the treatment of hypotension secondary to trauma

Intrathoracic pressure regulation (IPR) therapy has been shown to increase blood pressure in hypotensive patients. The potential value of this therapy in patients with hypotension secondary to trauma with blee...

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What your community needs to know about the 'Until Help Arrives' program

The program aims to teach bystanders how to keep victims with life-threatening injuries alive until EMS arrives

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Inscope Medical Solutions launches laryngoscope with integrated suction

The Inscope Direct is a disposable laryngoscope that gives clinicians a clear view of the airway

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Conn. fire, EMS crews receive body armor

An inter-town Capital Expenditure Grant from the state purchased tactical protective equipment to ensure the safety of first responders

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At the intersection of rural and remote: EMS at 40 below

When Kalie Klaysmat describes Crane Lake’s fire department as the end of the road, she’s not being fatalistic. "Crane Lake is literally at the end of the road – Route 24, to be exact," Klaysmat says of the northern Minnesota community five miles from the Canadian border. "When you get there, you can keep going in any of three directions, but you’re going to need ...

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EMCrit Podcast 211 – Expertise with Anders Ericsson

Expertise & Deliberate Practice with Anders Ericsson and @resuspadawan

EMCrit by Scott Weingart.

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EMCrit Podcast 211 – Expertise with Anders Ericsson

Expertise & Deliberate Practice with Anders Ericsson and @resuspadawan

EMCrit by Scott Weingart.

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Duplex ultrasound in the early diagnosis of acute mesenteric ischemia: a longitudinal cohort multicentric study

Objective: Acute mesenteric ischemia (AMI) is a life-threatening condition requiring time-dependent treatment; thus, early recognition may improve outcomes. We hypothesized that clinician-performed mesenteric vessels duplex ultrasound (DUS) could facilitate early identification of patients with AMI in high-risk patients presenting with abdominal pain. Methods: This was a single-operator, observational, prospective cohort study. Patients aged at least 65 presenting to Emergency Departments with acute abdominal pain and no clear diagnosis after an initial work-up were enrolled. All patients underwent multidetector computed tomography and these findings provided the reference standard in this study. DUS of the celiac artery and superior mesenteric artery (SMA) were obtained to measure the peak systolic velocity (PSV) and were performed within 24 h of admission. PSVs outside the normal range were considered to indicate AMI. Results: Of 49 patients identified, 47 were consented to enrollment and diagnostic images were obtained in 45 (96%). Fifteen patients (33%) had AMI (six occlusive, nine nonocclusive disease). Among these, 12 (80%) had abnormal DUS velocities. SMA PSV showed a sensitivity of 78.57% [95% confidence interval (CI): 49.2–95.34], a specificity of 64.52% (95% CI: 45.37–80.77), a positive predictive value of 50% (95% CI: 28.22–71.78), and a negative predictive value of 86.96% (95% CI: 66.41–97.22) for AMI. DUS had a sensitivity of 100%, a specificity of 64%, and a negative predictive value of 100% for occlusive AMI. Assessment of celiac artery PSV did not improve diagnostic performance. Conclusion: In this single-operator pilot study, mesenteric vessel DUS was performed successfully in the Emergency Department, with a high proportion of diagnostic images obtained. A normal SMA PSV was associated with a low risk of occlusive AMI.

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Mortality in Spanish pediatric emergency departments: a 5-year multicenter survey

Background: Analysis of the causes of death in children in the pediatric emergency department (ED) may aid the development of management and prevention practices. Objective: To identify the causes of death in Spanish pediatric EDs and to analyze the management of these children in the prehospital and hospital settings. Methods: This was a retrospective descriptive multicenter survey including all patients whose death was certified in 18 Spanish pediatric EDs between 2008 and 2013. Results: During the study period, 3 542 426 episodes were registered in the EDs. Of these, 54 patients died (mortality rate: 1.5/100 000 visits). Data of 53 patients are analyzed (male 36, 67%, 31 younger than 2 years old and 43.3% nonpreviously healthy children). The main causes of death were related to their previous illnesses (24.5%), sudden infant death syndrome (20.7%), and traumatism (18.8%). Prehospital cardiopulmonary resuscitation (CPR) was performed in 31 patients, and exclusively by health workers in 19 patients. In 35 patients, the parents witnessed the event and seven began CPR. Thirty children were transferred to the pediatric EDs by medical transport (56.6%) and all of them received prehospital CPR (vs. one patient out of 23 arrived in a nonmedical transportation). In 37 patients, CPR was performed in the pediatric EDs. Overall, CPR lasted 40±23 min (range, 10–120 min). CPR was not performed in seven patients at any time. Conclusion: The main causes of death in Spanish pediatric EDs are related to previous illnesses, sudden infant death syndrome, and nonintentional lesions. Several actions have to be considered to improve the quality of care of these children in prehospital and emergency settings.

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Strengths and weaknesses in team communication processes in a UK emergency department setting: findings using the Communication Assessment Tool-Team

Introduction: Identifying weaknesses in emergency department (ED) communication may highlight areas where quality improvement may be beneficial. This study explores whether the Communication Assessment Tool-Team (CAT-T) survey can identify communication strengths and weaknesses in a UK setting. Objectives: This study aimed to determine the frequency of patient responses for each item on the CAT-T survey and to compare the proportion of responses according to patient and operational characteristics. Methods: Adults presenting to the minors area of a semi-urban ED between April and May 2015 were included. Those lacking capacity or in custody were excluded. Multivariate analysis identified associations between responses and demographic/operational characteristics. Results: A total of 407/526 eligible patients responded (77.3%). Respondents were mostly White British (93.9%), with a median age of 45 years. Most responses were obtained during daytime hours (84.2% between 08 : 00 and 18 : 00). The median reported times to triage, assessment and disposition were 15, 35 and 90 min, respectively. Items most frequently rated as ‘very good’/‘excellent’ (strengths) were ‘ambulance staff treated me with respect’ (86.7%), ED staff ‘let me talk without interruptions’ (85%) and ‘paid attention to me’ (83.7%). Items most frequently rated as ‘poor’/‘fair’ (weaknesses) were ‘encouraged me to ask questions’, ‘reception treated me with respect’ (10.4%) and ‘staff showed an interest in my health’ (6.8%). Arrival time, analgesia at triage and time to assessment were associated with significantly increased odds of positive perception of team communication for a range of items. Conclusion: The CAT-T survey may be used within a UK setting to identify discrete strengths and weaknesses in ED team communication.

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Prehospital management and outcome of avalanche patients with out-of-hospital cardiac arrest: a retrospective study in Tyrol, Austria

Aim: The aim of this study is to describe the prehospital management and outcome of avalanche patients with out-of-hospital cardiac arrest in Tyrol, Austria, for the first time since the introduction of international guidelines in 1996. Patients and methods: This study involved a retrospective analysis of all avalanche accidents involving out-of-hospital cardiac arrest between 1996 and 2009 in Tyrol, Austria. Results: A total of 170 completely buried avalanche patients were included. Twenty-eight victims were declared dead at the scene. Of 34 patients with short burial, cardiopulmonary resuscitation (CPR) was performed in 27 (79%); 15 of these patients (56%) were transported to hospital with ongoing CPR and four patients were rewarmed with extracorporeal circulation; no patient survived. Of 108 patients with long burial, 49 patients had patent or unknown airway status; CPR was performed in 25 of these patients (51%) and 14 patients (29%) were transported to hospital. Four patients were rewarmed, but only one patient with witnessed cardiac arrest survived. Since the introduction of guidelines in 1996, there has been a marginally significant increase in the rate of documenting airway assessment, but no change in documenting the duration of burial or CPR. Conclusion: CPR is continued to hospital admission in patients with short burial and asphyxial cardiac arrest, but withheld or terminated at the scene in patients with long burial and possible hypothermic cardiac arrest. Insufficient transfer of information from the accident site to the hospital may partially explain the poor outcome of avalanche victims with out-of-hospital cardiac arrest treated with emergency cardiac care.

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Does it matter who places the intravenous? An inter-professional comparison of prehospital intravenous access difficulties between physicians and paramedics

Objectives: Depending on the specific national emergency medical systems, venous cannulations may be performed by physicians, paramedics or both alike. Difficulties in the establishment of vascular access can lead to delayed treatment and transport. Our study investigates possible inter-professional differences in the difficulties of prehospital venous cannulation. Methods: Paramedics were interviewed for their personal attitudes towards and experiences in venous access. We analysed 47 candidate predictor variables in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariable logistic regression models were fitted for variables of potential predictive value (P0.60) of their respective receiver operating characteristic curve. Results were compared with previously published data from emergency physicians. Results: A total of 552 cannulations were included in our study. All 146 participants voted that paramedics should be eligible to perform venous catheterizations. Despite ample experience in the task, almost half of them considered prehospital venous cannulations more difficult than those performed in hospital. However, the multivariable logistic regression found only patient-related and puncture site factors to be predictive of cannulation failure (patient age, vein palpability with tourniquet, insufficient ambient lighting: model AUC: 0.72) or cannulation delay (vein palpability with tourniquet: model AUC: 0.60). Conclusion: Our study shows that venous cannulation is well established among paramedics. It presents itself with similar difficulties across medical professions. Not the numerous specific circumstances of prehospital emergency care, but universal factors inherent to the task will influence the success at venous catheterization.

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Intermediate-term and long-term mortality among acute medical patients hospitalized with community-acquired sepsis: a population-based study

Objective: Admission with severe sepsis is associated with an increased short-term mortality, but it is unestablished whether sepsis severity has an impact on intermediate-term and long-term mortality following admission to an acute medical admission unit. Patients and methods: This was a population-based study of all adults admitted to an acute medical admission unit, Odense University Hospital, Denmark, from September 2010 to August 2011, identified by symptoms and clinical findings. We categorized the mortality periods into intermediate-term (31–180 days) and long-term (181–365, 366–730, and 731–1096 days). Mortality hazard ratios (HRs), comparing patients admitted with sepsis with those of a well-defined background population, were estimated using multivariable Cox regression. HRs were presented with 95% confidence intervals. Results: In total, 621 (36.3%) presented with sepsis, 1071 (62.5%) presented with severe sepsis, and 21 (1.2%) presented with septic shock. Thirty-day all-cause mortality for patients with sepsis, severe sepsis, and septic shock was 6.1, 18.8, and 38.1%, respectively. The adjusted HR among patients with sepsis of any severity within the time periods 31–180, 181–365, 366–720, and 721–1096 days was 7.1 (6.0–8.5), 2.8 (2.3–3.5), 2.1 (1.8–2.6), and 2.2 (1.7–2.9), respectively. Long-term mortality was unrelated to sepsis severity [721–1096 days: sepsis HR: 2.2 (1.5–3.2), severe sepsis HR: 2.1 (1.5–3.0)]. Conclusion: Patients admitted with community-acquired sepsis showed high intermediate-term mortality, increasing with sepsis severity. Long-term mortality was increased two-fold compared with sepsis-free individuals, but might be explained by unmeasured confounding. Further, long-term mortality was unrelated to sepsis severity.

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Implementing an electronic observation and early warning score chart in the emergency department: a feasibility study

Background: Use of automated systems to aid identification of patient deterioration in routine hospital practice is limited and their impact on patient outcomes remains unclear. This study was designed to evaluate the feasibility of implementing an electronic observation chart with automated early warning score (EWS) calculation in the high-acuity area of an emergency department. Methods: This study enrolled 3219 participants before and 3352 after implementation of an automated system, using bedside vital-sign entry on networked mobile devices. The primary outcome measure was the percentage of participants for whom an EWS was accurately recorded at each stage. Results: Of the participants, 52.7% before and 92.9% after implementation of the electronic system had an accurate EWS recorded on charts available to the study team. Participant groups were well balanced for baseline characteristics and acuity. Conclusion: In this study, the feasibility and limitations of implementing an electronic observation chart in the ED were demonstrated. Accurate EWS documentation was more frequent after implementation of the electronic observation chart. Retrospective analysis suggests that the use of an electronic observation system may lead to a greater percentage of observations being taken from those patients with a higher EWS.

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Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients

Objective: To evaluate the effect of routine use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) on the diagnosis rate of delirium in elderly Emergency Department (ED) patients and the validity of the CAM-ICU in the ED setting. Methods: This was a prospective observational study in a tertiary care academic ED. We compared the diagnosis rate of delirium before implementation of the CAM-ICU, without routine use of a screening tool, with the diagnosis rate after implementation of the CAM-ICU. All consecutive patients aged 70 years or older were enrolled. The diagnosis rate before implementation was based on chart review and after implementation on a positive CAM-ICU score. In a subsample, the presence of delirium was evaluated independently according to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) criteria to assess the validity of the CAM-ICU. Results: The total study population included 968 patients: 490 before and 478 after implementation of the CAM-ICU. The two groups were not significantly different in patient characteristics. Before implementation of the CAM-ICU, delirium was diagnosed in 14 patients (3%) and after implementation in 48 patients (10%) (P

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What will emergency care look like 10 years from now?

No abstract available

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The Abbreviated Mental Test 4 for cognitive screening of older adults presenting to the Emergency Department

Objectives: A commonly cited reason for the infrequent detection of cognitive impairment in the Emergency Department (ED) is the lack of an appropriate screening tool. The Abbreviated Mental Test 4 (AMT4) is a brief instrument recommended for cognitive screening of older adults in the ED. However, its exact utility in the detection of altered mental status in the ED is yet to be fully determined. Methods: The present study evaluated the ability of the AMT4 to identify impaired mental status in the ED, defined as positive scores on either the Confusion Assessment Method-ICU for delirium, the standardized Mini Mental State Examination as a general cognitive screener or the Eight-item Interview to Differentiate Aging and Dementia for dementia. Results: Of 196 adults at least 70 years of age (mean: 78.5±5.9), the AMT4 had a sensitivity of 0.53 (0.42–0.63) and a specificity of 0.96 (0.89–0.99) for impaired mental status in the ED. The AMT4 was positive in almost all patients (92%; 24/26) screening positive for delirium, but less than half (47.8%; 22/46) of those screening positive for probable dementia, and less than a quarter (22.2%; 6/27) of those screening positive for probable cognitive impairment. Conclusion: The present study found that the limited sensitivity of the AMT4 in identifying the majority of cognitively impaired persons restricts its use in isolation as a general cognitive screener in the ED.

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Intranasal fentanyl for the prehospital management of acute pain in children

Introduction: Acute pain is the most common symptom in the emergency setting and its optimal management continues to challenge prehospital emergency care practitioners, particularly in the paediatric population. Difficulty in establishing vascular access and fear of opiate administration to small children are recognized reasons for oligoanalgesia. Intranasal fentanyl (INF) has been shown to be as safe and effective as intravenous morphine in the treatment of severe pain in children in the Emergency Department setting. Aim: This study aimed to describe the clinical efficacy and safety of INF when administered by advanced paramedics in the prehospital treatment of acute severe pain in children. Methods: A 1-year prospective cross-sectional study was carried out of children (>1 year,

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How do patients with chest pain access Emergency Department care?

Background: It is important that patients with symptoms of acute coronary syndrome receive appropriate medical care as soon as possible. Little is known about the preadmission actions that patients with chest pain take before arrival at the Emergency Department (ED). Objective: This study aimed to describe the actions of patients with chest pain or pressure after onset of symptoms. What is the first action following onset of symptoms? Who is the first lay or professional person to be contacted? Which steps are taken first? How is the patient transported to the hospital? Methods: Consecutive patients, arriving at the ED of two large hospitals in Belgium, were asked additional questions during the initial assessment. Results: Overall, 35% of 412 consecutive patients with chest pain admitted to the ED were diagnosed with acute coronary syndrome. A total of 57% contacted a GP between symptom onset and arrival at the ED. Only 32% of the patients were transported to the ED by ambulance, 16% drove themselves and 52% arrived by other means of transport (by family, neighbour, GP, public transport). Conclusion: In Belgium, the GP is still the first professional to be contacted for most patients. Other patients initially rely on their partner, family or friends when symptoms emerge. Too often, patients with chest pain rely on other transport to get to the ED instead of calling the Emergency Medical Services. This study included only patients who ultimately attended the ED.

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Adolescent tracheal intubation in an adult urban emergency department: a retrospective, observational study

Objectives: Tracheal intubation is the cornerstone of advanced emergency airway management in children and adults and there is good-quality data characterizing intubation in both groups. There are, however, few published studies on emergency tracheal intubation in adolescents. We carried out an observational study to characterize tracheal intubation in adolescents. Methods: We analysed data from a previously collected Emergency Department Intubation Registry. We included all attempts at tracheal intubation performed in our adult emergency department between 1999 and 2011. We recorded the indication for intubation, the staff involved, the technique and drugs used, and the rates of successful intubation and adverse events. We classified patients into three age groups: 13–16 years (adolescent), 17–24 years (young adult) and at least 25 years (older adult). Results: Trauma was the most common indication for intubation in adolescents, and rapid sequence induction was used in 88% of cases. Ninety-nine percent of tracheal intubations in adolescent patients were successful on the first or the second attempt, no adolescent underwent more than three attempts and none required a surgical airway. The initial intubation attempt in adolescents was more likely to be performed by an anaesthetist (P

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Prognosis of patients with syncope seen in the emergency room department: an evaluation of four different risk scores recommended by the European Society of Cardiology guidelines

Aim: To apply, analyze, and evaluate the four syncope risk scores recommended by the 2009 European guidelines and the different parameters that they use to predict death, syncope recurrence, and hospital readmission in the population seen in the emergency room department (ERD) for syncope. Methods and results: A total of 323 patients aged older than 14 years [mean age 59 (32–75) years] and seen in ERD for syncope over a 2-month period were included in the study; 50.7% were women. Patients were evaluated using the four risk scores and were followed up for at least 2 years. In all, 275 patients (85.2%) were discharged directly from ERD after evaluation. During 28±5 months of follow-up, 8% died, 18.3% presented a further syncopal episode, and 18.6% were readmitted to hospital. Only two of the four risk scores were useful in risk discrimination, but no statistically significant differences were detected between predicted risk and observed risk. Multivariate analysis indicated relationships between age and death, a history of cardiovascular disease and syncope recurrence, and between presyncopal palpitations and hospital readmission. Conclusion: Although a large number of events occur after syncope, the risk scores recommended by guidelines overestimate risk, but there were no statistically significant differences between observed and predicted risk.

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Contamination of urinary cultures in initial-stream versus later-stream urine in children undergoing bladder catheterization for the diagnosis of urinary tract infection

Background: Urine cultures obtained by bladder catheterization can be contaminated by bacteria colonizing the distal urethra. Data are inconclusive regarding the potential advantage of discarding the first few urine drops obtained by bladder catheterization and testing only the sample of late-stream urine, thus reducing the likelihood of urine culture contamination. Aim: The aim of this study was to evaluate whether the incidence of contaminated urine cultures obtained by bladder catheterization can be reduced by splitting urine samples into ‘initial’ and ‘late’ samples and using only ‘late’ samples for culture. Methods: Urine samples obtained by bladder catheterization from children younger than 2 years being evaluated for urinary tract infection were prospectively collected. Quantitative culture results were compared between initial-stream and late-stream urine samples. Results: A total of 199 urine culture pairs of initial and late samples were compared. When using a cutoff value of at least 10 000 colony forming units/ml, late samples were superior to the initial ones in reducing contamination of urine cultures (P=0.029). Conclusion: When obtaining urine cultures by bladder catheterization in children younger than 2 years, discarding the first few urine drops and using only the late stream for culture reduces false-positive culture results and improves the accuracy of urinary tract infection diagnosis.

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Characteristics and outcome of patients presenting to the emergency department after autologous/allogeneic stem cell transplantation

Introduction: Hematopoietic stem cell transplantations are still associated with a high risk of complications. Here, we characterize patients after autologous or allogeneic transplantation presenting to the emergency department and investigate factors associated with patients’ outcome after hospitalization. Methods: Patients who had previously undergone autologous or allogeneic stem cell transplantation were included in this study and data were collected retrospectively. We analyzed patients’ characteristics and outcome, and identified factors associated with outcome. Results: A total of 35% of presenting autologous and 52% of allogeneic patients were hospitalized for more than 7 days. In-hospital mortality was 4% (autologous) and 11% (allogeneic patients). In patients with a history of autologous transplantation, multivariate analysis indicated radiologic signs of pneumonia as an independent factor associated with the endpoint ‘hospitalization of more than 7 days’ (P

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Top Ten Abstracts of the Tenth European Congress on Emergency Medicine, Vienna, October 2016.

No abstract available

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iSepsis – Death by Fluid, Part 3

The CLASSIC trial is a exploratory RCT comparing a fluid "restrictive" with a more liberal approach to fluid management in patients with septic shock

EMCrit by Paul Marik.

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iSepsis – Death by Fluid, Part 3

The CLASSIC trial is a exploratory RCT comparing a fluid "restrictive" with a more liberal approach to fluid management in patients with septic shock

EMCrit by Paul Marik.

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Charleston County EMS (SC) - Charleston County EMS

Voted one of the top tourist destinations in the world, Charleston County EMS serves over 1,100 square miles of historic and scenic areas including City of Charleston, Kiawah Island, and highly regarded beach communities on the Atlantic coastline. Charleston County is an EMS system that relies on Innovation, Trust, Compassion, Respect and Dedication to provide exceptional customer service to our community ...

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A MULTICENTER EVALUATION OF THE OPTIMAL TIMING OF SURGICAL STABILIZATION OF RIB FRACTURES.

Introduction: The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that 1) demographic, radiologic, and clinical variables are associated with time to surgery and 2), shorter time to SSRF improves acute outcomes. Methods: Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF [early ( 24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups. Results: 551 patients were analyzed. The median time to SSRF was 1 day (range 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the mid group, and 186 (31.9%) in the late group. There was a significant shift towards earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p

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Stop the Bleed Education Consortium: Education Program Content & Delivery Recommendations.

No abstract available

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Is it safe? Nonoperative management of blunt splenic injuries in geriatric trauma patients.

Background: Due to increased failure rates of non-operative management (NOM) of blunt splenic injuries (BSI) in the geriatric population, dogma dictated that this management was unacceptable. Recently, there has been an increased use of this treatment strategy in the geriatric population. However, published data assessing the safety of NOM of BSI in this population is conflicting and well-powered multicenter data is lacking. Methods: We performed a retrospective analysis of data from the National Trauma Data Bank (NTDB) from 2014 and identified young (age = 65) patients with a BSI. Patients who underwent splenectomy within 6 hours of admission were excluded from the analysis. Outcomes were failure of NOM and mortality. Results: We identified 18,917 total patients with a BSI, 2,240 (12%) geriatric patients and 16,677 (88%) young patients. Geriatric patients failed NOM more often than younger patients (6% vs 4%, p=16 was the only independent risk factor associated with failure of NOM in geriatric patients (OR=2.778, CI=1.769 - 4.363, p =16, GCS

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Delirium in the Pediatric Cardiac Extracorporeal Membrane Oxygenation Patient Population: A Case Series

Objective: To determine the prevalence of delirium in children who require extracorporeal membrane oxygenation. Design: Prospective observational longitudinal cohort study. Setting: Urban academic cardiothoracic ICU. Patients: All consecutive admissions to the cardiothoracic ICU who required venoarterial extracorporeal membrane oxygenation support. Interventions: Daily delirium screening with the Cornell Assessment for Pediatric Delirium. Measurements and Main Results: Eight children required extracorporeal membrane oxygenation during the study period, with a median extracorporeal membrane oxygenation duration of 202 hours (interquartile range, 99–302). All eight children developed delirium during their cardiothoracic ICU stay. Seventy-two days on extracorporeal membrane oxygenation were included in the analysis. A majority of patient days on extracorporeal membrane oxygenation were spent in coma (65%). Delirium was diagnosed during 21% of extracorporeal membrane oxygenation days. Only 13% of extracorporeal membrane oxygenation days were categorized as delirium free and coma free. Delirium screening was successfully completed on 70/72 days on extracorporeal membrane oxygenation (97%). Conclusions: In this cohort, delirium occurred in all children who required venoarterial extracorporeal membrane oxygenation. It is likely that this patient population has an extremely high risk for delirium and will benefit from routine screening in order to detect and treat delirium sooner. This has potential to improve both short- and long-term outcomes. This study was performed at New York Presbyterian Hospital, Columbia University Medical Center. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: apatel4@childrensnational.org ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Interagency Board releases recommended fentanyl exposure best practices

The board included best practices for PPE, decontamination and medical countermeasures

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Behind the wheel of an ambulance: Training needed

Fire and EMS agencies owe their crews, and the citizens they serve and protect, competent fire apparatus and ambulance driver/operators

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Sigmoid volvulus: the first one thousand-case single center series in the world

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What it's like joining London Ambulance Service

Fancy a new adventure? Listen to Michaela Shaw, who is training to be a Paramedic, outline her work as Emergency Ambulance Crew and consider a career with us - http://bit.ly/2d3v8z6

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Disseminating and Sustaining Emergency Department Innovations for Older Adults: Good Ideas Deserve Better Policies

Older adults often visit the emergency department (ED) with chief complaints that understate or detract from their true complex health care needs. These needs are frequently missed because addressing them requires a time-consuming effort that is antithetical to the (necessarily) rapid, complaint-specific protocols of the ED. Key ED performance indices (e.g., length of stay; through-put) also create a disincentive against undertaking comprehensive geriatric assessments when not clearly germane to the chief complaint. However, ignoring these complex care issues can contribute to poor health outcomes. These visits often serve as sentinel events in the patient's health trajectory which irreversibly hastens loss of independence. Such encounters will only increase as the population ages.

This article is protected by copyright. All rights reserved.

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Air ambulance delivery and administration of 4-factor prothrombin complex concentrate is feasible and decreases time to anticoagulation reversal

Abstract

Objectives

To evaluate the feasibility, safety, and preliminary efficacy of four-factor prothrombin complex concentrate (4-factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin-associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4-factor PCC following transfer by air ambulance or ground without 4-factor PCC treatment (conventional arm).

Methods

Retrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4-factor PCC from April 1^st 2014 through June 30^th 2016 were identified For this study, only transfer patients with an INR >1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, ICU length of stay and in-patient mortality between groups.

Results

Of the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤1.5 on ED arrival (proportion difference 0.82, 95% CI 0.64 to 0.92; p < 0.0001) and significantly reduced time to observed INR ≤1.5 (181 vs 541 minutes; p = 0.001). No differences were observed in thromboembolic complications or patient-centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale and higher intubation rates prior to transfer and treatment.

Conclusions

Dispatch of an air ambulance carrying 4-factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin-associated major hemorrhage.

This article is protected by copyright. All rights reserved.

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20 more thoughts only a paramedic will understand

By EMS1 Staff Paramedics are a special breed. There are many thoughts only you will understand, and there's absolutely nothing wrong with that. We've all experienced the tones dropping before a shift change and have thought to ourselves, "Really"" And you haven't been in EMS long enough if you don't yell "Clear right!" when you're driving off-duty. Our Facebook ...

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Training and Assessing Critical Airway, Breathing and Hemorrhage Control Procedures for Trauma Care: Live Tissue versus Synthetic Models

Abstract

Introduction

Optimal teaching and assessment methods and models for emergency airway, breathing and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus Live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing 7 procedures: Junctional hemorrhage control, Tourniquet (TQ) placement, Chest seal, Needle thoracostomy (NCD), Nasopharyngeal airway (NPA), Tube thoracostomy, and Cricothyrotomy (Cric).

Methods

Army combat medics were randomized to one of four groups: 1) Live tissue trained – live tissue tested (LT-LT), 2) live tissue trained – synthetic training model tested (LT-STM), 3) synthetic training model trained – live tissue tested (STM-LT), 4) synthetic training model trained – synthetic training model tested (STM-STM). Participants trained in small groups for 3-4 hours and were evaluated individually. LT-LT was the “control” to which other groups were compared, as this is the current military pre-deployment standard. The mean procedural scores (PS) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CF) and skipped tasks.

Results

There were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT tested subjects (LT-LT and STM-LT) skipped this task more than STM tested subjects (LT-STM and STM-STM) (p<0.05), and STM-STM had higher PS than LT-LT (p<0.001). For TQ, both STM tested groups (LT-STM and STM-STM) had more CFs than LT-LT (p<0.001) and LT-STM had lower PS than LT-LT (p<0.05). No differences were seen for chest seal. For NCD, LT-STM had greater CFs than LT-LT (p=0.001), and lower PSs (p=0.001). There was no difference in CFs for NPA, but all groups had worse PS versus LT-LT (p<0.05). For Cric, we were underpowered; STM-LT trended towards more CFs (p=0.08), and STM-STM had higher PSs than LT-LT (p<0.01). Tube thoracostomy revealed STM-LT had higher CFs than LT-LT (p<0.05), but LT-STM had lower PS (p<0.05). An interaction effect (making the subjects who trained and tested on different models more likely to CF) was only found for Tourniquet, chest seal and Cric, however, of these 3 procedures, only TQ demonstrated any significant difference in CF rates.

Conclusion

Training on STM or LT did not demonstrate a difference in subsequent performance for 5 of 7 procedures (junctional hemorrhage, TQ, chest seal, NPA and NCD). Until synthetic training models are developed with improved anthropomorphic and tissue fidelity, there may still be a role for LT for training tube thoracostomy and potentially cricothyrotomy. For assessment, our STM appears more challenging for TQ and potentially for NCD than LT. For junctional hemorrhage, the increased “skips” with LT may be explained by the differences in anatomic fidelity. While these results begin to uncover the effects of training and assessing these procedures on various models, further study is needed to ascertain how well performance on an STM or LT model translates to the human model.

This article is protected by copyright. All rights reserved.

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What it's like joining London Ambulance Service

Fancy a new adventure? Listen to Michaela Shaw, who is training to be a Paramedic, outline her work as Emergency Ambulance Crew and consider a career with us - http://bit.ly/2d3v8z6

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What it's like joining London Ambulance Service

Fancy a new adventure? Listen to Michaela Shaw, who is training to be a Paramedic, outline her work as Emergency Ambulance Crew and consider a career with us - http://bit.ly/2d3v8z6

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Behind the wheel of an ambulance: Training needed

Fire and EMS agencies owe their crews, and the citizens they serve and protect, competent fire apparatus and ambulance driver/operators

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What it's like joining London Ambulance Service

Fancy a new adventure? Listen to Michaela Shaw, who is training to be a Paramedic, outline her work as Emergency Ambulance Crew and consider a career with us - http://bit.ly/2d3v8z6

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Permissive hypotensive resuscitation in adult patients with traumatic haemorrhagic shock: a systematic review

Abstract

Background

Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its effectiveness on the survival rate remains unexplored. This detailed systematic review aims to critically evaluate the available literature that investigates the effects of PHR on survival rate.

Methods

A systematic review design searched for comparative and non-comparative studies using EMBASE, MEDLINE, PubMed, Web-of-Science and CENTRAL. Full-text articles on adult trauma patients with low blood pressure were considered for inclusion. The risk of bias and a critical appraisal of the identified articles were performed to assess the quality of the selected studies. Included studies were sorted into comparative and non-comparative studies to ease the process of analysis. Mortality rates of PHR were calculated for both groups of studies.

Results

From the 869 articles that were initially identified, ten studies were selected for review, including randomised control trials (RCTs) and cohort studies. By applying the risk of bias assessment and critique tools, the methodologies of the selected articles ranged from moderate to high quality. The mortality rates among patients resuscitated with low volume and large volume in the selected RCTs were 21.5% (123/570) and 28.6% (168/587) respectively, whilst the total mortality rate of the patients enrolled in three non-comparative studies was 9.97% (279/2797).

Conclusions

The death rate amongst post-trauma patients managed with conservative resuscitation was lower than standard aggressive resuscitation, which indicates that PHR can create better survival rate among traumatised patients. Therefore, PHR is a feasible and safely practiced fluid resuscitative strategy to manage haemorrhagic shock in pre-hospital and in-hospital settings. Further trials on PHR are required to assess its effectiveness on the survival rate.

Level of evidence

Systematic review, level III.

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Neutrophil Phenotype Correlates With Postoperative Inflammatory Outcomes in Infants Undergoing Cardiopulmonary Bypass

Objectives: Infants with congenital heart disease frequently require cardiopulmonary bypass, which causes systemic inflammation. The goal of this study was to determine if neutrophil phenotype and activation status predicts the development of inflammatory complications following cardiopulmonary bypass. Design: Prospective cohort study. Setting: Tertiary care PICU with postoperative cardiac care. Patients: Thirty-seven patients 5 days to 10 months old with congenital heart disease requiring cardiopulmonary bypass. Interventions: None. Measurements and Main Results: Laboratory and clinical data collected included length of mechanical ventilation, acute kidney injury, and fluid overload. Neutrophils were isolated from whole blood at three time points surrounding cardiopulmonary bypass. Functional analyses included measurement of cell surface protein expression and nicotinamide adenine dinucleotide phosphate oxidase activity. Of all patients studied, 40.5% displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity in response to N-formyl-Met-Leu-Phe stimulation 24 hours post cardiopulmonary bypass as compared to pre bypass. Neonates who received steroids prior to bypass demonstrated enhanced priming of nicotinamide adenine dinucleotide phosphate oxidase activity at 48 hours. Patients who displayed priming post cardiopulmonary bypass were 8.8 times more likely to develop severe acute kidney injury as compared to nonprimers. Up-regulation of neutrophil surface CD11b levels pre- to postbypass occurred in 51.4% of patients, but this measure of neutrophil priming was not associated with acute kidney injury. Subsequent analyses of the basal neutrophil phenotype revealed that those with higher basal CD11b expression were significantly less likely to develop acute kidney injury. Conclusions: Neutrophil priming occurs in a subset of infants undergoing cardiopulmonary bypass. Acute kidney injury was more frequent in those patients who displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity after cardiopulmonary bypass. This pilot study suggests that neutrophil phenotypic signature could be used to predict inflammatory organ dysfunction. † Deceased. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/2gIrZ5Y). Supported, in part, by the University of Iowa Children’s Miracle Network Training Grant (Number 2218) and the University of Iowa Infectious Disease T32 Training Grant (Number 5-T32-AI 07343-20) Dr. Huber received funding from University of Iowa Children’s Miracle Network Grant. Dr. Brophy disclosed other funding from the American Board of Pediatrics, the American Society of Pediatric Nephrology, and UpToDate. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Jessica.Moreland@UTSouthwestern.edu ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Contemporary Postnatal Incidence of Acquiring Acute Myocarditis by Age 15 Years and the Outcomes From a Nationwide Birth Cohort

Objectives: Acute myocarditis can be lethal, but the incidence remains unclear because of its wide manifestation spectrum. We investigated the postnatal incidence of acute myocarditis and risk factors for morbidity and mortality. Design: Retrospective derived birth cohort study. Setting: Taiwan National Health Insurance Database for the period 2000–2014. Patients: Children born between 2000 and 2009 with complete postnatal medical care data for at least 5 years. Interventions: None. Measurements and Main Results: From among 2,150,590 live births, we identified 965 patients (54.8% male) admitted with the diagnosis of acute myocarditis, accounting for an overall incidence of 0.45/1,000. The cumulative incidence rates were 0.19/1,000, 0.38/1,000, 0.42/1,000, and 0.48/1,000 by ages 1, 5, 10, and 15 years, respectively. Male predominance was noted in infants and school age children (age group 6–14 yr). Arrhythmias, including tachyarrhythmia (4.8%) and bradyarrhythmia (1.1%), occurred in 56 patients. Extracorporeal membrane oxygenation support was provided to 62 patients (6.4%) and additional left ventricular assist devices in six of them. The mortality at discharge was 6.3%. The presence of ventricular tachyarrhythmia, bradyarrhythmia, and an onset at school age (6–14 yr) were associated with increased odds for the need for extracorporeal membrane oxygenation, which was the only predictor for mortality at discharge (hazard ratio, 7.85; 95% CI, 3.74–9.29). In patients who survived the acute myocarditis, late mortality was relatively low (36/904 = 4.0%). The overall survival of children with acute myocarditis were 90.9%, 90.3%, and 89.8% by the intervals of 1, 5, and 10 years after the myocarditis, respectively. Conclusions: This birth cohort study determined the cumulative incidence of acute myocarditis for neonates by 15 years old to be one in 2,105. In an era of extracorporeal membrane oxygenation, the need of extracorporeal membrane oxygenation may reflect the severity of acute myocarditis and predict its outcome. Supported, in part, by grants from Taiwan Ministry of Science and Technology (103-2314-B-002 -054 -MY3 and 106-2314-B-002-218). Drs. and Kao disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: wumh@ntu.edu.tw ©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Should We Manage All Septic Patients Based on a Single Definition? An Alternative Approach

No abstract available

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Twenty-Four-Hour Intensivist Staffing Is Not Beneficial for Patients

No abstract available

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Outcomes of Ventilated Patients With Sepsis Who Undergo Interhospital Transfer: A Nationwide Linked Analysis

Objectives: The outcomes of critically ill patients who undergo interhospital transfer are not well understood. Physicians assume that patients who undergo interhospital transfer will receive more advanced care that may translate into decreased morbidity or mortality relative to a similar patient who is not transferred. However, there is little empirical evidence to support this assumption. We examined country-level U.S. data from the Nationwide Readmissions Database to examine whether, in mechanically ventilated patients with sepsis, interhospital transfer is associated with a mortality benefit. Design: Retrospective data analysis using complex survey design regression methods with propensity score matching. Setting: The Nationwide Readmissions Database contains information about hospital admissions from 22 States, accounting for roughly half of U.S. hospitalizations; the database contains linkage numbers so that admissions and transfers for the same patient can be linked across 1 year of follow-up. Patients: From the 2013 Nationwide Readmission Database Sample, 14,325,172 hospital admissions were analyzed. There were 61,493 patients with sepsis and on mechanical ventilation. Of these, 1,630 patients (2.7%) were transferred during their hospitalization. A propensity-matched cohort of 1,630 patients who did not undergo interhospital transfer was identified. Interventions: None. Measurements and Main Results: The exposure of interest was interhospital transfer to an acute care facility. The primary outcome was hospital mortality; the secondary outcome was hospital length of stay. The propensity score included age, gender, insurance coverage, do not resuscitate status, use of renal replacement therapy, presence of shock, and Elixhauser comorbidities index. After propensity matching, interhospital transfer was not associated with a difference in in-hospital mortality (12.3% interhospital transfer vs 12.7% non–interhospital transfer; p = 0.74). However, interhospital transfer was associated with a longer total hospital length of stay (12.8 d interquartile range, 7.7–21.6 for interhospital transfer vs 9.1 d interquartile range, 5.1–17.0 for non–interhospital transfer; p

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Racial and Geographic Disparities in Interhospital ICU Transfers

Objectives: Interhospital transfer, a common intervention, may be subject to healthcare disparities. In mechanically ventilated patients with sepsis, we hypothesize that disparities not disease related would be found between patients who were and were not transferred. Design: Retrospective cohort study. Setting: Nationwide Inpatient Sample, 2006–2012. Patients: Patients over 18 years old with a primary diagnosis of sepsis who underwent mechanical ventilation. Interventions: None. Measurements and Main Results: We obtained age, gender, length of stay, race, insurance coverage, do not resuscitate status, and Elixhauser comorbidities. The outcome used was interhospital transfer from a small- or medium-sized hospital to a larger acute care hospital. Of 55,208,382 hospitalizations, 46,406 patients met inclusion criteria. In the multivariate model, patients were less likely to be transferred if the following were present: older age (odds ratio, 0.98; 95% CI, 0.978–0.982), black race (odds ratio, 0.79; 95% CI, 0.70–0.89), Hispanic race (odds ratio, 0.79; 95% CI, 0.69–0.90), South region hospital (odds ratio, 0.79; 95% CI, 0.72–0.88), teaching hospital (odds ratio, 0.31; 95% CI, 0.28–0.33), and do not resuscitate status (odds ratio, 0.19; 95% CI, 0.15–0.25). Conclusions: In mechanically ventilated patients with sepsis, we found significant disparities in race and geographic location not explained by medical diagnoses or illness severity. New affiliation for Dr. McLennan: Institute for Biomedical Ethics, Universität Basel, Basel, Switzerland. Drs. Tyler, Celi, and Rush contributed in conception and design; Dr. Rush contributed in statistics; and all authors contributed to interpretation and drafting the article for important intellectual content. Dr. Celi received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: pdtyler@bidmc.harvard.edu Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Safety and Feasibility of Early Physical Therapy for Patients on Extracorporeal Membrane Oxygenator: University of Maryland Medical Center Experience

Objectives: To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous oxygenation support. Design: Retrospective cohort study. Setting: Medical and Surgical ICUs in a large tertiary care hospital in the United States. Patients: Adults supported on extracorporeal membranous oxygenation from January 2014 to December 2015. Measurements and Main Results: We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (

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Significance of Mini Bronchoalveolar Lavage Fluid Amylase Level in Ventilator-Associated Pneumonia: A Prospective Observational Study

Objectives: Aspiration of oropharyngeal or gastric contents in intubated patients can lead to ventilator-associated pneumonia. Amylase in respiratory secretion has been reported as a possible marker of aspiration. We studied whether elevated α-amylase in mini bronchoalveolar lavage specimens can be suggestive of ventilator-associated pneumonia in intubated patients with high clinical suspicion. Design: Prospective single-center observational study. Setting: Department of Critical Care Medicine, tertiary care academic institute. Patients: Adult patients on mechanical ventilation for more than 48 hours with with clinically suspected ventilator-associated pneumonia as per defined criteria, admitted between December 2014 and May 2016. Methods: Mini bronchoalveolar lavage samples were collected within 72 hours of endotracheal intubation. Samples were sent for α-amylase level assay and quantitative culture. Ventilator-associated pneumonia was confirmed from mini bronchoalveolar lavage microbial culture of greater than or equal to 104 cfu/mL, and patients were divided into ventilator-associated pneumonia and no ventilator-associated pneumonia groups. Pre- and postintubation risk factors for aspiration were also noted. Results: The prevalence of ventilator-associated pneumonia was 64.9% among 151 patients in whom it was clinically suspected. Median (interquartile range) mini bronchoalveolar lavage α-amylase levels in ventilator-associated pneumonia and no ventilator-associated pneumonia groups on the day of study inclusion were 287 U/L (164–860 U/L) and 94 U/L (59–236 U/L), respectively (p

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Development and Validation of an Abbreviated Questionnaire to Easily Measure Cognitive Failure in ICU Survivors: A Multicenter Study

Objectives: To develop and validate an abbreviated version of the Cognitive Failure Questionnaire that can be used by patients as part of self-assessment to measure functional cognitive outcome in ICU survivors. Design: A retrospective multicenter observational study. Setting: The ICUs of two Dutch university hospitals. Patients: Adult ICU survivors. Interventions: None. Measurements and Main Results: Cognitive functioning was evaluated between 12 and 24 months after ICU discharge using the full 25-item Cognitive Failure Questionnaire (CFQ-25). Incomplete CFQ-25 questionnaires were excluded from analysis. Forward selection in a linear regression model was used in hospital A to assess which of the CFQ-25 items should be included to prevent a significant loss of correlation between an abbreviated and the full CFQ-25. Subsequently, the performance of an abbreviated Cognitive Failure Questionnaire was determined in hospital B using Pearson’s correlation. A Bland-Altman plot was used to examine whether the reduced-item outcome scores of an abbreviated Cognitive Failure Questionnaire were a replacement for the full CFQ-25 outcome scores. Among 1,934 ICU survivors, 1,737 were included, 819 in hospital A, 918 in hospital B. The Pearson’s correlation between the abbreviated 14-item Cognitive Failure Questionnaire (CFQ-14) and the CFQ-25 was 0.99. The mean of the difference scores was –0.26, and 95% of the difference scores fell within +5 and –5.5 on a 100-point maximum score. Conclusions: It is feasible to use the abbreviated CFQ-14 to measure self-reported cognitive failure in ICU survivors as this questionnaire has a similar performance as the full CFQ-25. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://ift.tt/29S62lw). This work was performed at Radboud university medical center and University Medical Centre Utrecht. Drs. Wassenaar, de Reus, Donders, Schoonhoven, Pickkers, and van den Boogaard contributed in study concept and design. Drs. Cremer, van Dijk, de Lange, Slooter, and van den Boogaard contributed in acquisition of data. Drs. Wassenaar, de Reus, and Donders contributed in statistical analysis. Drs. Wassenaar, de Reus, and van den Boogaard contributed in analysis and interpretation of data. Drs. Wassenaar and de Reus contributed in drafting of the article. Drs. Donders, Schoonhoven, Cremer, de Lange, van Dijk, Slooter, Pickkers, and van den Boogaard contributed in critical revision of the article for important intellectual content. Drs. Pickkers and van den Boogaard contributed in study supervision. Dr. Schoonhoven contributed to study cosupervision. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Mark.vandenBoogaard@radboudumc.nl Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Medic CE How To Use Live Course Calendar for VILT EMS Refresher

Medic-CE Virtual Instructor Led CAPCE F5 EMS Refreshers - www.medic-ce.com RE-CERTIFY ONLINE!

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Medic CE How To Use Live Course Calendar for VILT EMS Refresher

Medic-CE Virtual Instructor Led CAPCE F5 EMS Refreshers - www.medic-ce.com RE-CERTIFY ONLINE!

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Medic CE How To Use Live Course Calendar for VILT EMS Refresher

Medic-CE Virtual Instructor Led CAPCE F5 EMS Refreshers - www.medic-ce.com RE-CERTIFY ONLINE!

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Link: Fixed Dose PCC

this is how PCC should be given...

EMCrit by Scott Weingart.

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Link: Fixed Dose PCC

this is how PCC should be given...

EMCrit by Scott Weingart.

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Medic CE How To Use Live Course Calendar for VILT EMS Refresher

Medic-CE Virtual Instructor Led CAPCE F5 EMS Refreshers - www.medic-ce.com RE-CERTIFY ONLINE!

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Treating first responder mental health, addiction, PTSD and suicide

A new fire/EMS-specific treatment facility caters to specific job-related trauma while making first responders feel at home

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Treating first responder mental health, addiction, PTSD and suicide

This article first appeared on FireRehab.com, sponsored by Masimo. By Daniel Martynowicz, EMS1 Contributor Most in the fire/EMS community have a harrowing story of death, destruction and despair. These stories usually involve heartbreak and pain – not just for the victims involved, but also for the first responders tasked with restoring order to the chaos, perfusion to the pulseless, and hope ...

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Texas school district partners with fire department for EMT academy

By EMS1 Staff PFLUGERVILLE, Texas — A school district teamed up with a fire department to launch the first-ever EMT academy in the area for high school seniors. Statesman reported that six high school seniors from Connally High School and Hendrickson High School began participating in the academy as a result of a partnership between the Pflugerville school district and Pflugerville Fire Department ...

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Fla. fire department to add ballistic armor to ambulance

Gainesville Fire Rescue plans to add ballistic protection to the ambulance’s front, sides and back to protect against handgun-caliber bullets

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REMSA releases comprehensive white paper on its nationally acclaimed community health programs

RENO, Nev. — REMSA, the Regional Emergency Medical Services Authority based in northern Nevada, has released a new comprehensive White Paper that provides detailed information on its highly successful Community Health Programs. These nationally-acclaimed programs were launched in 2012 after REMSA received funding through a $9.1 million Health Care Innovation Award grant from the Center for Medicare ...

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EMT-led laryngeal tube vs. face-mask ventilation during cardiopulmonary resuscitation - a multicenter prospective randomized trial

Laryngeal tube (LT) application by rescue personnel as an alternate airway during the early stages of out-of-hospital cardiac arrest (OHCA) is still subject of debate. We evaluated ease of handling and efficac...

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Tesla turns power on at Puerto Rico children’s hospital

Hospital del Nino, which serves around 3,000 children, has power again in the wake of Hurricane Maria thanks to a new solar power system

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What would you tell your 21-year-old EMS self?

By EMS1 Staff EMS1 columnist Michael Morse put together a list of things he would tell his younger EMS self. Morse included advice such as continually studying anatomy, the importance of always looking presentable and keeping mental health at the top of the priority list. Following the "If I knew then what I know now" mentality, we asked our Facebook fans to reflect on what they would tell ...

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