The Period 2 Enhancer Nobiletin as Novel Therapy in Murine Models of Circadian Disruption Resembling Delirium

Objectives: Delirium occurs in approximately 30% of critically ill patients, and the risk of dying during admission doubles in those patients. Molecular mechanisms causing delirium are largely unknown. However, critical illness and the ICU environment consistently disrupt circadian rhythms, and circadian disruptions are strongly associated with delirium. Exposure to benzodiazepines and constant light are suspected risk factors for the development of delirium. Thus, we tested the functional role of the circadian rhythm protein Period 2 (PER2) in different mouse models resembling delirium. Design: Animal study. Setting: University experimental laboratory. Subjects: Wildtype, Per2–/– mice. Interventions: Midazolam, lipopolysaccharide (lipopolysaccharide), constant light, nobiletin, or sham-treated animals. Measurements and Main Results: Midazolam significantly reduced the expression of PER2 in the suprachiasmatic nucleus and the hippocampus of wild-type mice. Behavioral tests following midazolam exposure revealed a robust phenotype including executive dysfunction and memory impairment suggestive of delirium. These findings indicated a critical role of hippocampal expressed PER2. Similar results were obtained in mice exposed to lipopolysaccharide or constant light. Subsequent studies in Per2–/– mice confirmed a functional role of PER2 in a midazolam-induced delirium-like phenotype. Using the small molecule nobiletin to enhance PER2 function, the cognitive deficits induced by midazolam or constant light were attenuated in wild-type mice. Conclusions: These experiments identify a novel role for PER2 during a midazolam- or constant light–induced delirium-like state, highlight the importance of hippocampal PER2 expression for cognitive function, and suggest the PER2 enhancer nobiletin as potential therapy in delirium-like conditions associated with circadian disruption. Nobiletin used to treat delirium is not labeled for the use of delirium and is still investigational. 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. Eckle received a grant from the National Institutes of Health-National Heart, Lung, and Blood Institute (NIH-NHLBI) 5R01HL122472. Dr. Eckle received support for article research from the NIH. Dr. Eckle’s institution received funding from the NIH/NHLBI. Ms. Gile and Dr. Scott disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: tobias.eckle@ucdenver.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2COAaGw

Presepsin and Inflammatory Markers Correlate With Occurrence and Severity of Nonocclusive Mesenteric Ischemia After Cardiovascular Surgery

Objectives: To prospectively evaluate the relationship of established inflammatory markers and presepsin on nonocclusive mesenteric ischemia and to correlate presepsin levels to the occurrence and severity of nonocclusive mesenteric ischemia. Design: Patients were prospectively enrolled and blood samples taken, followed by a retrospective evaluation of laboratory values and angiographic findings. The study was ethics committee approved. Settings: Patients with clinical suspicion of nonocclusive mesenteric ischemia underwent catheter angiography of the superior mesenteric artery. Images were assessed by two experienced radiologists on consensus basis using a previously published standardized reporting system (Homburg-Nonocclusive Mesenteric Ischemia-Score). Two groups were formed according to the severity of nonocclusive mesenteric ischemia, mild and severe, patients without clinical signs of nonocclusive mesenteric ischemia formed the reference group. These data were correlated to inflammatory blood markers assessed pre- and postoperatively: C-reactive protein, leucocytes, procalcitonin, and presepsin as well as outcome data. Patients: Between January 2010 and March 2011, a total of 839 patients undergoing cardiovascular surgery participated in this study. Measurements and Main Results: Mild nonocclusive mesenteric ischemia was diagnosed in 4.5%, and severe nonocclusive mesenteric ischemia in 3.2%. Median postoperative presepsin concentrations were significantly greater in mild and severe nonocclusive mesenteric ischemia than in non-nonocclusive mesenteric ischemia. Statistics showed that postoperative presepsin better discriminated mild and severe nonocclusive mesenteric ischemia than any other tested biomarker. Conclusions: Elevated postoperative plasma presepsin concentrations are an independent predictor of mild and severe nonocclusive mesenteric ischemia. The established inflammatory blood markers significantly correlate with the development and severity of nonocclusive mesenteric ischemia. Drs. Groesdonk and Minko have equally contributed to the conception and design, as well as acquisition of data, and analysis and interpretation of data. Drs. Groesdonk and Minko drafted the article and revised it critically. Drs. Groesdonk and Minko approved the final version of the article and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Dr. Stroeder received funding from Bracco. Dr. Buecker received funding from Editorship RoeFo, and he received other funding from Editorship Investigative Radiology Chairman R.W. Günther Stiftung. Dr. Groesdonk received funding from Mitsubishi Pharma Europe. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Jonas.Stroeder@uks.eu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2COddDs

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients

Publication date: Available online 28 February 2018
Source:The Journal of Emergency Medicine
Author(s): Steven T. Riccoboni, Michael A. Darracq
BackgroundBehavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer.ObjectiveWe sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care.MethodsWe performed a retrospective chart review of all patients transferred to an in-network BH from September 1–30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay.ResultsThere were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093.ConclusionThe UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2CsB9Re

Physician-provided prehospital critical care, effect on patient physiology dynamics and on-scene time

Introduction Improved physiologic status can be seen as a surrogate measure of improved outcome and a field-friendly prognostic model such as the Mainz Emergency Evaluation Score (MEES) could quantify the effect on physiological response. We aim to examine the dynamic physiological profile as measured by this score on patients managed by physician-manned helicopter emergency medical services and how this profile was related to on-scene time expenditure and critical care interventions. Materials and methods Data including patient characteristics, physiological data, and description of diagnostic and therapeutic interventions were prospectively collected over two 14-day periods, summer and winter, at six participating Norwegian bases. The MEES score was utilized to examine the difference between a score measured at first patient contact (MEES 1) and end-of-care (MEES 2), (MEES 2–MEES 1=[INCREMENT]MEES). Results A total of 240 primary missions with patient-on-scene form the basis of the study. In total, 43% were considered severely ill or injured, of whom 59% were medical patients. Twenty-nine percent were severely deranged physiologically. The most common advanced procedure performed was advanced airway management (15%), followed by defibrillation (8.8%). Using [INCREMENT]MEES as an indicator, 1% deteriorated under care, whereas 66% remained unchanged and 33% showed an improvement in their physiological status. With increasing on-scene time, fewer patients deteriorated and a greater proportion of patients improved. Conclusion Restoring deranged physiology remains a mantra for all critical care practitioners. We have shown that this is also possible in the prehospital context, even when prolonging on-scene time, and after initiating advanced procedures.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BVEzec

Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial

Objective Recent studies suggest that administration of O2 in patients with acute myocardial infarction may have negative effects. With the use of cardiac MRI (CMR), we evaluated the effects of supplemental O2 in patients with ST elevation myocardial infarction (STEMI) accepted for acute percutaneous coronary intervention (PCI). Materials and methods This study was a randomized-controlled trial conducted at two university hospitals in Sweden. Normoxic STEMI patients were randomized in the ambulance to either supplemental O2 (10 l/min) or room air until the conclusion of the PCI. CMR was performed 2–6 days after the inclusion. The primary endpoint was the myocardial salvage index assessed by CMR. The secondary endpoints included infarct size and myocardium at risk. Results At inclusion, the O2 (n=46) and air (n=49) patient groups had similar patient characteristics. There were no significant differences in myocardial salvage index [53.9±25.1 vs. 49.3±24.0%; 95% confidence interval (CI): −5.4 to 14.6], myocardium at risk (31.9±10.0% of the left ventricle in the O2 group vs. 30.0±11.8% in the air group; 95% CI: −2.6 to 6.3), or infarct size (15.6±10.4% of the left ventricle vs. 16.0±11.0%; 95% CI: −4.7 to 4.1). Conclusion In STEMI patients undergoing acute PCI, we found no effect of high-flow oxygen compared with room air on the size of ischemia before PCI, myocardial salvage, or the resulting infarct size. These results support the safety of withholding supplemental oxygen in normoxic STEMI patients.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FDuceS

Characteristics and predictors of mortality among frequent users of an Emergency Department in Switzerland

Objectives Frequent Emergency Department (ED) users have an elevated mortality, yet little is known about risk factors. Our aim was to characterize deceased frequent ED users and determine predictors of mortality. Methods This is a post-hoc analysis of all-cause mortality among frequent ED users participating in a randomized clinical trial on case management at the Lausanne University Hospital (Switzerland). We enrolled 250 frequent ED users (5+ visits/past year) in a 12-month randomized clinical trial; those with an estimated survival of fewer than 18 months were excluded. The primary outcome was 12-month all-cause mortality. We performed descriptive statistics to compare the baseline characteristics of living and deceased participants, and examined predictors of all-cause mortality using logistic regressions, including age adjustment. Results Twenty of the 250 (8%) frequent users died during the 12-month follow-up. Seven (35%) deaths were because of cardiac causes and six (30%) were because of cancer. The median age at death was 71 years. Deceased participants were older and more likely to report any somatic determinant, chronic illness, and medical comorbidity. Age (odds ratio 1.07, 95% confidence interval 1.04–1.11) and medical comorbidity (odds ratio 4.76, 95% confidence interval 1.86–12.15) were statistically significant predictors of mortality. Conclusion Despite excluding those with an estimated survival of fewer than 18 months, 8% of frequent ED users died during the study. Age and medical comorbidity were significant predictors of mortality. Interventions, such as case management, should target older frequent ED users and those with multiple medical conditions, and future research should explore their potential impact on mortality.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2t9D09R

Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study

Background Sepsis is a common condition in the emergency department (ED). Lactate measurement is an important part of management: arterial lactate (A-LACT) measurement is the gold standard. There is increasing use of peripheral venous lactate (PV-LACT); however, there is little research supporting the interchangeability of the two measures. If PV-LACT has good agreement with A-LACT, it would significantly reduce patient discomfort and the risks of arterial sampling for a large group of acutely unwell patients, while allowing faster and wider screening, with potential reduced costs to the healthcare system. Objective The aim of this study is to determine the agreement between PV-LACT and A-LACT in septic patients attending the ED. Methods We carried out a prospective observational cohort study of 304 consented patients presenting with sepsis to a single UK NHS ED (110 000 adult attendances annually) taking paired PV-LACT and A-LACT. Bland–Altman analysis was carried out to determine agreement. Receiver operating characteristic curves and 2×2 tables were constructed to explore the predictive value of PV-LACT for A-LACT. Results The mean difference (PV-LACT−A-LACT) is 0.4 mmol/l [95% confidence interval (CI): 0.37–0.45], with 95% limits of agreement from −0.4 (95% CI: −0.45 to −0.32) to 1.2 (95% CI: 1.14–1.27). A PV-LACT of at least 2 mmol/l predicts an A-LACT of at least 2 with 100% sensitivity (95% CI: 89–100%) and 83% specificity (95% CI: 77–87%). Conclusion This study is the largest comparing the two measurements, and shows good clinical agreement. We recommend using PV-LACT in the routine screening of septic patients. A PV-LACT less than 2 mmol/l is predictive of an A-LACT less than 2 mmol/l.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FEywur

Virtual Laboratory and Imaging: an online simulation tool to enhance hospital disaster preparedness training experience

Objective Hospitals play a pivotal role as basic healthcare providers during mass casualty incidents (MCIs). Radiological studies and emergency laboratory test are of high importance for the management of hospital patients. However, it is known that during these events, they can generate significant bottlenecks. Appropriate request of such tests is of utmost importance to not generate delays in the patient flow. The aim of this paper is to describe a software designed to increase the realism of hospital-based MCI training through a realistic reproduction of radiology and laboratory departments. Methods In this paper, we present a Virtual Laboratory and Imaging system that we designed with the goal of increasing the realism of full-scale mass casualty simulations. The system is able to dynamically manage the speed and load of virtual departments while collecting data on usage and load, and provide data useful for the after-event debriefing. We tested this system in two pilot simulations involving, respectively, 105 and 89 simulated casualties. Results The system, by measuring the number of requests and exams’ turnaround time, enabled an objective measurement of the laboratory and radiology workload during simulated MCIs. It was possible to identify bottlenecks and consequently use these data for after-action debriefing. Conclusion The tool not only increased the simulation realism by adding the radiology and laboratory departments but also provided valuable data that could be used for educational and organizational purposes.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BVOIHz

Agreement between arterial and venous lactate in emergency department patients: a prospective study of 157 consecutive patients

Introduction In the emergency department (ED), lactate is routinely used for risk stratification. Whether venous or arterial lactate measured on blood gas is interchangeable is not known. We hypothesized that venous lactate can be used instead of arterial lactate for the evaluation of acute patients in the ED. Patients and methods This was a prospective single-center study. All patients requiring a lactate measurement were enrolled and we simultaneously drew arterial and venous blood. We followed up all patients to hospital discharge. Our primary aim was to evaluate agreements between the two measurements using Bland and Altman plots with the report of bias (mean difference) and limits of agreements. We also aimed to determine the rate of misclassification (defined as one measurement2.2). Our secondary aim was to evaluate their respective prognostic value to predict in-hospital death or admission in the ICU longer than 72 h. Results The mean age of the 132 analyzed patients was 62 years (SD: 18 years), and 59% were men. The mean difference (bias) between arterial and venous lactate was −0.6 mmol/l (limits of agreement: −1.7 to 0.6 mmol/l). The rate of misclassification was 8% (95% confidence interval: 3–2%). Both methods present similar performances for the prediction of poor outcomes, with an area under the receiving operator characteristic curves of 0.67 for both. Results were similar when focused only on septic patients. Conclusion Venous and arterial lactates do not agree well, and there is a high misclassification rate. Venous lactate does not appear to be interchangeable with arterial sampling.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FE0Ht8

Ethical and scientific misconduct: the beginner’s experience

No abstract available

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BVlsAQ

Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study

Objective Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock. Methods Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined. Results A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival. Conclusion Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FE5YBb

Telemedicine-based physician consultation results in more patients treated and released by ambulance personnel

Objective We examined whether teleconsultation from ambulances to a physician at an emergency medical communication center (EMCC) would increase the proportion of patients with nonurgent conditions being treated and released on site. Methods This research was a before–after pilot study. In the intervention period, the EMCC was manned 24/7 with physicians experienced in emergency care. Eligible participants included all patients with nonurgent conditions receiving an ambulance after a medical emergency call. Ambulance personnel assessed patients and subsequently performed a telephone consultation from the ambulance with the physician. The primary outcome was the proportion of patients treated and released on site. Secondary outcomes were the number of hospital admissions, mortality, and patient satisfaction. The intervention period was compared with a corresponding control period from the previous year. Results We observed an increase in the proportion of patients treated and released in the intervention period in 2014 compared with the control period in 2013, up from 21% (n=137) to 29% (n=221) (odds ratio=1.46; 95% confidence interval=1.14–1.89, P=0.002). The follow-up rate was 100%. There was no observable increase in hospital admissions or mortality among patients treated and released from 2013 to 2014. A telephone survey of patients treated and released showed that 98.4% (95% confidence interval=91.3–99.9) were very satisfied or satisfied with their treatment. Conclusion Teleconsultation between a physician at the EMCC and ambulance personnel and noncritically ill 1-1-2 patients results in an increased rate of patients treated and released with high satisfaction. The approach does not seem to compromise patient safety.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BUElUA

Nonspecific abdominal pain in the Emergency Department: malignancy incidence in a nationwide Swedish cohort study

Introduction The role of emergency physicians is to identify patients in need of immediate treatment, but also to identify symptoms indicative of serious, if not immediately life-threatening conditions. Aim To assess whether symptoms described as nonspecific abdominal pain (NSAP) could be the first indication of an abdominal malignancy. Materials and methods This was a nationwide registry-based cohort study of all patients discharged with NSAP from Swedish Emergency Departments (EDs) during the year 2011, based on Swedish patient registries of inpatient and outpatient care, and the cause of death registry, studying patients diagnosed with de novo cancer within a year after their NSAP discharge. Results Of 24 801 patients discharged with NSAP in 2011, 2.2% were assigned a cancer diagnosis within 12 months. Almost 20% of patients diagnosed with a malignancy died within the year, and 16% of these deaths occurred within a month after the ED visit. The majority of patients with cancer were 60 years of age or older, and thus significantly older than the remaining NSAP patients. Patients with malignancies also had a greater number of comorbidities than the remaining NSAP patients (P

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FCeQXW

Workplace chemical and toxin exposures reported to a Poisons Information Centre: a diverse range causing variable morbidity

Objective The aim of this study is to determine the period prevalence, nature and causes of workplace chemical and toxin exposures reported to the Victorian Poisons Information Centre (VPIC). Patients and methods All cases classified as ‘workplace: acute’ when entered into the VPIC database (June 2005–December 2013) were analysed. Data were collected on patient sex, the nature of the chemical or toxin, route of exposure and season. Results Overall, 4928 cases were extracted. Exposures to men (71.5% of calls) differed from women (P

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2t3xoNZ

Is severe hypercalcemia immediately life-threatening?

Objective Severe hypercalcemia is often considered an emergency because of a potential risk of cardiac arrest or coma. However, there is little evidence to support this. The aim of our study was to assess whether severe hypercalcemia (Ca>4 mmol/l or 16 mg/dl) was associated with immediately life-threatening cardiac arrhythmias or neurological complications in patients admitted to the Emergency Department (ED). Methods A retrospective observational study was carried out over a 5-year period (2008–2012). Eligible patients were admitted to the Adult Emergency Department of Nantes University Hospital and had a calcium concentration in excess of 4 mmol/l. There were no exclusion criteria. The primary outcome was the number of life-threatening cardiac arrhythmias and/or neurological complications during the stay in the ED. The secondary outcomes were correlation between calcium concentrations/ECG QTc intervals and mortality. Results A total of 126 204 adult patients had calcium concentrations measured. Thirty one (0.025%) patients had severe hypercalcemia as defined in our study. The median calcium concentration was 4.3 mmol/l (Q1, 4.2; Q3, 4.7) and the median albumin-adjusted calcium concentration was 4.3 mmol/l (Q1, 4.1; Q3, 4.7). No patient presented with a life-threatening cardiac event during stay in the ED. The median ED stay was 7 h 32 min. One patient presented with a coma of multifactorial origin. There was no correlation between calcemia and QTc intervals (P=0.60). Mortality at 1 year was 55% (17 patients). Conclusion We found no cases of immediately life-threatening cardiac arrhythmias or neurological complications associated with hypercalcemia above 4 mmol/l over a 5-year period in a large tertiary ED.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FE5QSd

Introducing copayments in the emergency department would deter appropriate visits in the Netherlands

Objective To determine what the effects of introduction of copayments for self-referred emergency department (ED) visits would be in the Netherlands and at what amount patients would turn to a GP before visiting an ED. Methods This questionnaire study was carried out in the ED of the Rijnstate Hospital, a community teaching hospital in the Netherlands. In the Netherlands, a deductible excess system is in use and this study investigated the effects of a copayment for self-referred patients (SRPs) on top of the deductible excess. A questionnaire was developed and handed out to SRPs. Results A total of 433 SRPs were included; their average age was 33.1 years and 63% were male. With a copayment of €100, 47% of SRPs would choose to visit their GP instead of the ED. A further increase in the copayment amount is largely ineffective in reducing the number of self-referred ED visits. The higher the household income and education level and the more urgent the triage category, the larger the copayment patients are willing to pay. There is no significant relation between appropriateness and the amount of copayment that patients are willing to pay and we found no specific copayment level that resulted in reducing mainly inappropriate ED visits. Conclusion With a copayment of €100, 47% of the SRPs would choose to visit their GP instead of the ED. There was no specific copayment level that resulted in reducing mainly inappropriate ED visits.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BVEveg

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation

Saline vs. balanced solutions has been a topic of ongoing debate.  Two fresh studies will illuminate this: the SMART and SALT-ED trials.  This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1.  There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]

EMCrit Project by Josh Farkas.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EZGQYn

K911 - Preparing for Medicare's New MBI Format

Sponsored by ZOLL Data Management. In this Knowledge911 video on the RescueNet Billing system, we’ll be walking you through the steps necessary to prepare your system for the new Medicare MBI numbers. Medicare expects to roll out this new format in April of 2018 and you’ll need to prepare your system beforehand to accommodate these new identification numbers.

from EMS via xlomafota13 on Inoreader http://ift.tt/2t3TXSZ

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation

Saline vs. balanced solutions has been a topic of ongoing debate.  Two fresh studies will illuminate this: the SMART and SALT-ED trials.  This post summarizes current knowledge, beginning with physiology and working our way to fresh trials. Reason #1.  There is no physiologic rationale for using “normal” saline (NS). Saline is a hypertonic, acidotic fluid […]

EMCrit Project by Josh Farkas.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EZGQYn

Climate of Respect Evaluation in ICUs: Development of an Instrument (ICU-CORE)

Objectives: To develop a valid, reliable measure that reflected the environment of respectfulness within the ICU setting. Design: We developed a preliminary survey instrument based on conceptual domains of respect identified through prior qualitative analyses of ICU patient, family member, and clinician perspectives. The initial instrument consisted of 21 items. After five cognitive interviews and 16 pilot surveys, we revised the instrument to include 23 items. We used standard psychometric methods to analyze the instrument. Settings: Eight ICUs serving adult patients affiliated with a large university health system. Subjects: ICU clinicians. Interventions: None. Measurements and Main Results: Based on 249 responses, we identified three factors and created subscales: General Respect, Respectful Behaviors, and Disrespectful Behaviors. The General Respect subscale had seven items (α = 0.932) and reflected how often patients in the ICU are treated with respect, in a dignified manner, as an individual, equally to all other patients, on the “same level” as the ICU team, as a person, and as you yourself would want to be treated. The Respectful Behaviors subscale had 10 items (α = 0.926) and reflected how often the ICU team responds to patient and/or family anxiety, makes an effort to get to know the patient and family as people, listens carefully, explains things thoroughly, gives the opportunity to provide input into care, protects patient modesty, greets when entering room, and talks to sedated patients. The subscale measuring disrespect has four items (α = 0.702) and reflects how often the ICU team dismisses family concerns, talks down to patients and families, speaks disrespectfully behind their backs, and gets frustrated with patients and families. Conclusions: We created a reliable set of scales to measure the climate of respectfulness in intensive care settings. These measures can be used for ongoing quality improvement that aim to enhance the experience of ICU patients and their families. Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at Johns Hopkins University. REDCap is a secure, web-based application designed to support data capture for research studies, providing 1) an intuitive interface for validated data entry, 2) audit trails for tracking data manipulation and export procedures, 3) automated export procedures for seamless data downloads to common statistical packages, and 4) procedures for importing data from external sources. 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 National Institutes of Health (NIH) George and Betty Moore Foundation. Dr. Beach’s, Ms. Topazian’s, and Drs. Sugarman’s and Geller’s institutions received funding from the George and Betty Moore Foundation. Dr. Beach’s institution also received funding from the National Institutes of Health (NIH) (K24 Grant) and the Greenwall Foundation; and she received support for article research from the NIH. Dr. Sugarman disclosed that he serves on the Merck KGaA Bioethics Advisory Panel and Stem Cell Research Oversight Committee, Quintiles’ Ethics Advisory Panel, and he has consulted with Novartis on a bioethics issue (none of which are related to the content of this article). Dr. Geller received support for article research from the Gordon and Betty Moore Foundation. Dr. Chan has disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: mcbeach@jhmi.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2GOjP78

Biological Response to Time-Controlled Adaptive Ventilation Depends on Acute Respiratory Distress Syndrome Etiology

Objectives: To compare a time-controlled adaptive ventilation strategy, set in airway pressure release ventilation mode, versus a protective mechanical ventilation strategy in pulmonary and extrapulmonary acute respiratory distress syndrome with similar mechanical impairment. Design: Animal study. Setting: Laboratory investigation. Subjects: Forty-two Wistar rats. Interventions: Pulmonary acute respiratory distress syndrome and extrapulmonary acute respiratory distress syndrome were induced by instillation of Escherichia coli lipopolysaccharide intratracheally or intraperitoneally, respectively. After 24 hours, animals were randomly assigned to receive 1 hour of volume-controlled ventilation (n = 7/etiology) or time-controlled adaptive ventilation (n = 7/etiology) (tidal volume = 8 mL/kg). Time-controlled adaptive ventilation consisted of the application of continuous positive airway pressure 2 cm H2O higher than baseline respiratory system peak pressure for a time (Thigh) of 0.75–0.85 seconds. The release pressure (Plow = 0 cm H2O) was applied for a time (Tlow) of 0.11–0.18 seconds. Tlow was set to target an end-expiratory flow to peak expiratory flow ratio of 75%. Nonventilated animals (n = 7/etiology) were used for Diffuse Alveolar Damage and molecular biology markers analyses. Measurement and Main Results: Time-controlled adaptive ventilation increased mean respiratory system pressure regardless of acute respiratory distress syndrome etiology. The Diffuse Alveolar Damage score was lower in time-controlled adaptive ventilation compared with volume-controlled ventilation in pulmonary acute respiratory distress syndrome and lower in time-controlled adaptive ventilation than nonventilated in extrapulmonary acute respiratory distress syndrome. In pulmonary acute respiratory distress syndrome, volume-controlled ventilation, but not time-controlled adaptive ventilation, increased the expression of amphiregulin, vascular cell adhesion molecule-1, and metalloproteinase-9. Collagen density was higher, whereas expression of decorin was lower in time-controlled adaptive ventilation than nonventilated, independent of acute respiratory distress syndrome etiology. In pulmonary acute respiratory distress syndrome, but not in extrapulmonary acute respiratory distress syndrome, time-controlled adaptive ventilation increased syndecan expression. Conclusion: In pulmonary acute respiratory distress syndrome, time-controlled adaptive ventilation led to more pronounced beneficial effects on expression of biomarkers related to overdistension and extracellular matrix homeostasis. Drs. Silva, Cruz, Samary, and Moraes contributed equally to this work. Drs. Andrews, Habashi, Nieman, and Rocco share senior authorship. 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 Brazilian Council for Scientific and Technological Development (CNPq), the Rio de Janeiro State Research Foundation (The Carlos Chagas Filho Rio de Janeiro State Research Supporting Foundation [FAPERJ]), the Coordination for the Improvement of Higher Education Personnel, and the Department of Science and Technology—Brazilian Ministry of Health. Dr. Silva received support for article research from FAPERJ and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Drs. de Magalhães and Bose received support for article research from CNPq. Drs. Gatto, Andrews, Nieman, and Habashi have lectured for Intensive Care Online Network (ICON). Dr. Gatto received funding from the Canadian Society of Respiratory Therapists (lecture honorarium). Drs. Andrews, Habashi, and Nieman have presented and received honoraria and/or travel reimbursement at events sponsored by Dräger Medical Systems, outside of the published work. Dr. Andrews received funding from lectures at conferences sponsored by Draeger Medical and ICON (reimbursement for travel expenses and honorarium). Dr. Habashi received funding from lecturing at industry sponsored events including Draeger Medical (travel expenses and honorarium) and disclosed having patents in the area of mechanical ventilation (although no money from stocks, royalties, or license fees have been received); he is the founder of ICON, of which Dr. Andrews is an employee; and he holds patents on a method of initiating, managing, and/or weaning airway pressure release ventilation, as well as controlling a ventilator in accordance with the same, but these patents are not commercialized, licensed, nor royalty producing. Dr. Nieman received funding from Draeger Medical. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Patricia R. M. Rocco, MD, PhD, Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, 21941-902, Rio de Janeiro, Brazil. E-mail: prmrocco@gmail.com Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2HRpLNY

The effect of multidisciplinary extracorporeal membrane oxygenation team on clinical outcomes in patients with severe acute respiratory failure

The Extracorporeal Life Support Organization (ELSO) has suggested that extracorporeal membrane oxygenation (ECMO) patients should be managed by a multidisciplinary team. However, there are limited data on the ...

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2ETRa44

Gender Bias in the Management of Patients Still Exists

Abstract

In this volume of Academic Emergency Medicine, Humphries et al, report that females with cardiac chest pain and cardiac troponin levels above the 99^th percentile are less likely to receive guideline recommended care for an acute coronary syndrome (ACS). By using strict criteria, the authors attempted to adjust for differences in presentation and adding to existing literature showing that gender bias exists even when objective criteria are used.

This article is protected by copyright. All rights reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2ot2oCx

Neutrophil-to-lymphocyte ratio as a feasible prognostic marker for pyogenic liver abscess in the emergency department

Abstract

Purpose

The neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with for various conditions. To date, there are no previous studies on NLR as a prognostic marker for pyogenic liver abscess (PLA), especially on admission to the emergency department (ED).

Methods

From January 2013 to December 2015, 102 patients diagnosed with PLA in the ED were included. Clinico-radiological and laboratory results, including NLR, were evaluated as variables. NLR was calculated as absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of PLA, data on hospital mortality, intensive care unit (ICU) admission, and development of septic shock were obtained. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

Results

Among 102 patients, 10 (9.8%) died, 14 (13.7%) were admitted to the ICU, and 15 (14.7%) developed septic shock during hospitalization. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting death [odds ratio (OR), 1.4; p = 0.020], ICU admission (OR, 1.4; p = 0.021), and development of septic shock (OR, 1.6; p = 0.041). NLR showed an excellent predictive performance for death (areas under the ROC curves [AUC], 0.941; cut-off value, 19.7; p < 0.001), ICU admission (AUC, 0.946; cut-off value, 16.9; p < 0.001), and development of septic shock (AUC, 0.927; cut-off value, 16.9; p < 0.001).

Conclusion

NLR was positively associated with poor prognosis of PLA; elevated NLR could predictor of high risk of death, ICU admission, and development of septic shock. Emergency physicians should consider NLR for the prognosis of PLA and early aggressive treatment, especially in patients with NLR > 16.9.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EWExl3

Unplanned readmission after hospital discharge in burn patients in Iran

Abstract

Introduction

Burns are considered as one of the most serious health problems throughout the world. They may lead to adverse consequences and outcomes. One of these outcomes is unplanned readmission. Unplanned readmission has been commonly used as a quality indicator by hospitals and governments. This study aimed to determine the predictors of unplanned readmission in patients with burns hospitalized in a burn center in the North of Iran (Guilan province, Rasht).

Methods

This retrospective analytic study has been done on the medical records of hospitalized patients with burns in Velayat Sub-Specialty Burn and Plastic Surgery Center, Rasht, Iran during 2008–2013. In general, 703 medical records have been reviewed but statistical analysis was performed on 626 medical records. All data were entered in SPSS (version 16) and analyzed by descriptive and inferential statistics.

Results

Among 626 patients with burns, the overall readmission rate was 5.1%. Predictors of readmission included total body surface area (OR 1.030, CI 1.011–1.049), hypertension (OR 2.923, CI 1.089–7.845) and skin graft (OR 7.045, CI 2.718–18.258).

Conclusion

Considering the outcome, predictors following burn have a crucial role in the allocation of treatment cost for patients with burns and they can be used as one of the quality indicators for health care providers and governments.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FvyDIz

The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures

Abstract

Objectives

Goal of this study was to investigate whether a gravity stress radiograph is beneficial in determining instability in Supination-External rotation (SER)-type ankle fractures without a medial fracture.

Methods

39 Patients with a SER-type ankle fracture without a medial or posterior fracture and medial clear space (MCS) < 6 mm at regular mortise view were included. A gravity stress radiograph and Magnetic Resonance imaging (MRI)-scan were made. The MCS measurements of the regular and gravity stress radiographs were compared with the MRI findings (set as reference standard) to determine the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values as indication for a complete deltoid ligament rupture.

Results

Mean MCS at regular mortise views was 3.11 (range 1.73–5.93) mm, compared to 4.54 (range 2.33–10.40) mm at gravity stress radiographs. With MCS ≥ 4 mm as threshold for predicting a complete rupture at regular ankle mortise views the sensitivity was 66.7, specificity 91.7, PPV 40.0 and NPV 97.0. Gravity stress radiographs with MCS ≥ 6 mm as threshold led to a sensitivity of 100, specificity 91.7, PPV 50.0 and NPV 100.

Conclusion

Gravity stress radiographs have more discriminative ability for diagnosing SER-type fractures with or without a complete deltoid ligament tear than regular ankle mortise views.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EVqlbU

Deep coma does not always predict poor outcomes among patients with polytrauma

Abstract

Purposes

This study aimed to clarify the prognosis of polytrauma patients presenting to the emergency department (ED) with a Glasgow Coma Scale score (GCS) of 3.

Methods

A trauma registry system has been established at our institution since 2009. The current study reviewed patients in the registry who presented to the ED with a GCS of 3 from January 2011 to December 2015. Surviving and non-surviving patients were compared to identify the prognostic factors of patient survival. The study also aimed to determine the factors contributing to patients who survived with a GCS > 13 at discharge.

Results

During the study period, 145 patients were enrolled in the study, 119 of whom (82.1%) did not survive the traumatic insult. Of the 26 survivors, 13 (9.0%) had a GCS of 14 or 15 at discharge. The multiple logistic regression revealed that a lack of bilateral dilated and fixed pupils (BFDP) (OR 5.967, 95% CI 1.780–19.997, p = 0.004) and a GCS > 3 after resuscitation (OR 6.875, 95% CI 2.135–22.138, p = 0.001) were independent prognostic factors of survival. Based on the multiple logistic regression, an age under 40 years (OR 16.405, 95% CI 1.520–177.066, p = 0.021) and a GCS > 3 after resuscitation (OR 12.100, 95% CI 1.058–138.352, p = 0.045) were independent prognostic factors of a GCS > 13 at discharge.

Conclusion

Aggressive resuscitation still provided benefit to polytrauma patients presenting with a GCS of 3, especially those with a rapid response to the resuscitation. Young patients with a deep coma on arrival had a higher probability of functional recovery after resuscitation in the ED.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FwejXv

Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach

Abstract

Introduction

The timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.

Methods

Retrospective analysis of all consecutive patients subjected to LC + IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (± SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).

Results

During the 29-month study, a total of 201 consecutive LC + IO-ERCPs were performed. The mean age of patients was 55 ± 19 years and 67% were female. The mean intervention time was 105 ± 44 min. The total LOS was 4 (3,  7) days and the post-operative LOS was 2 (1,  3) days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.

Conclusion

Simultaneous LC + IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EUHl22

Analysis of quality of life after major trauma: a spanish follow-up cohort study

Abstract

Purpose

Study objectives are to determine whether quality of life is recovered completely after major injury and to identify determinants associated with a worse quality of life.

Methods

Prospective 12-month follow-up of injured patients admitted to the intensive care unit in a Spanish level 1 trauma centre. The main outcome (quality of life) was measured using the EQ-5D-5L. The relationships between sociodemographic factors, injury severity and location, and quality of life scores were evaluated. Mean comparison analysis (95% confidence interval) was performed with the student “t” test for quantitative variables and with chi-squared for proportion comparison (qualitative variables). A multivariate logistic regression (odds ratio and 95% confidence interval) was performed to identify determinants of each dimension, and a multivariate linear regression (regression coefficient and 95% confidence interval) to identify the determinants of EQus and EQvas.

Results

Over a 2-year period, 304 patients who met the inclusion criteria were identified, and 200 patients (65.8%) were finally included. Most of patients suffered blunt trauma (91.5%), 72.5% were men, mean age was 47.8, mean ISS was 15.2. The overall health index (EQvas) improved slightly, but its mean value at 12 months was below the Spanish population norm (P < 0.001). In the multivariate analysis, age ≥ 55, female gender and unskilled employment were risk factors for a lower EQvas. Also in the multivariate analysis, having a severe extremity injury was associated with a lower score on the mobility dimension (OR 6.56 95% CI 2.00, 21.55) while age ≥ 55 years was associated with a lower score on the usual activities dimension (OR 3.52 95% CI 1.17, 10.57). Female gender was the most important factor associated with suffering pain (OR 4.54, 95% CI 2.01, 10.27) and depression/anxiety (OR 4.04, 95% CI 1.88, 8.65). In the univariate and multivariate analyses, female gender, age ≥ 55 years, ISS ≥ 25 and severe extremity injury were associated with a lower EQ utility score (EQus).

Conclusions

The quality of life score improves during the first year after major trauma. However, it does not return to the reference levels for the normal population. Female gender and age ≥ 55 years are statistically significant determinants of poorer EQvas and EQus.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FuoZWx

Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis

Abstract

Purpose

Many studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks.

Methods

PubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications.

Results

A total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes.

Conclusions

Results of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2ETsLru

Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications

Abstract

Background

Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications.

Methods

A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU^®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA).

Results

Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed.

Conclusion

Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FvMLl0

Pre-hospital management of pediatric polytrauma during modern conflict: experience and limits of the French military health service

Abstract

Background

French military physicians serving in deployment are confronted with pediatric polytrauma patients (PPP) during the provision of medical aid to civilian populations. The objectives of this study were to describe the current care of PPPs during these missions, to report difficulties encountered and to evaluate the training of doctors for management of PPPs in the field.

Methods

A descriptive epidemiological study based on a questionnaire sent to physicians who had been deployed overseas.

Results

91 doctors participated. Their mean age was 35 years. 86% of the doctors managed children whilst serving overseas, of which 54% were PPPs. The incidence of pediatric polytrauma varied according to the country, but overall from 1129 emergencies reported during overseas missions, 11% were PPPs. Penetrating traumas represented 37% of cases; 24% were circulatory distress and 19% were massive bleeding. 80% of the doctors reported a lack of pediatric trauma experience, less than 5% had received appropriate in-service training and only 9% had worked in pediatric emergency facilities in France. The equipment available for PPPs in the field was often poorly understood and frequently considered to be insufficient.

Conclusions

The occurrence of PPPs of war is rare and complex, but care of older children it is similar to that required for adults. Preparation for PPP management, it could be optimized by identifying risks which alter depending on the country of deployment, such as the logistical organization of the battlefield chain of care. Improvements in doctors’ pediatric trauma training should be individualized, based on their mission needs.

Level of evidence

III.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EVmPyf

Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis

Abstract

Purpose

In patients following severe trauma sometimes the physiological condition or soft tissue status may not allow definitive fixation of a femoral fracture. In these patients, an external fixator can be placed to temporarily stabilise the fracture, after which definitive fixation can be performed in a second procedure. The aim of this study was to compare the postoperative wound infection and union rates of patients treated with direct intramedullary nailing (IMN) and patients treated with the ‘two-stage treatment’.

Methods

All patients with high-energy femoral fractures treated with IMN between 2000 and 2016 in a single Level 1 trauma centre were eligible. Electronic charts were reviewed for patient and surgical characteristics; furthermore, the development of complications was noted. A propensity score analysis was performed to assess the attributed risk of the external fixator on the development of postoperative wound infections.

Results

A total of 149 patients were included in this study; 93 underwent direct IMN and 56 underwent the two-stage treatment. Patients who underwent two-stage treatment were more severely injured, reflected by lower EMV and higher ISS on admission. Patients in the two-stage treatment group had a significant higher risk of postoperative wound infections (OR: 4.698, 95% CI: 1.203–18.339) but not a higher risk on deep postoperative wound infections (OR 2.345, 95% CI: 0.439–12.540). Union rate did not differ between the two groups (94% vs 94% NS).

Conclusions

The two-stage treatment is a safe treatment option in patients with a high-energy femoral fracture in terms of postoperative wound infections. Union rates are also comparable between the two treatment groups.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2HO08Og

Focus on imaging in trauma

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2GMzBzI

Correction to: Traumatic inferior shoulder dislocation: a review of management and outcome

The original version of this article unfortunately contained mistakes. The presentation of the author names was incorrect.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2HO08he

Prognostic Value of Secretoneurin in Patients With Severe Sepsis and Septic Shock: Data From the Albumin Italian Outcome Sepsis Study

Objectives: Secretoneurin directly influences cardiomyocyte calcium handling, and circulating secretoneurin levels seem to improve risk prediction in patients with myocardial dysfunction by integrating information on systemic stress, myocardial function, and renal function. Accordingly, in this study, we hypothesized that secretoneurin would improve risk prediction in patients with sepsis and especially in patients with septic shock as these patients are more hemodynamically unstable. Design: Multicenter, interventional randomized clinical trial. Setting: Multicenter, pragmatic, open-label, randomized, prospective clinical trial testing fluid administration with either 20% human albumin and crystalloids or crystalloid solutions alone in patients with severe sepsis or septic shock (The Albumin Italian Outcome Sepsis). Patients or Subjects: In total, 540 patients with septic shock and 418 patients with severe sepsis. Interventions: Either 20% human albumin and crystalloids or crystalloid solutions alone. Measurements and Main Results: We measured secretoneurin on days 1, 2, and 7 after randomization and compared the prognostic value of secretoneurin for ICU and 90-day mortality with established risk indices and cardiac biomarkers in septic shock and severe sepsis. High secretoneurin levels on day 1 were associated with age and serum concentrations of lactate, bilirubin, creatinine, and N-terminal pro-B-type natriuretic peptide. Adjusting for established risk factors and cardiovascular biomarkers, secretoneurin levels on day 1 were associated with ICU (odds ratio, 2.27 [95% CI, 1.05–4.93]; p = 0.04) and 90-day mortality (2.04 [1.02–4.10]; p = 0.04) in patients with septic shock, but not severe sepsis without shock. Secretoneurin levels on day 2 were also associated with ICU (3.11 [1.34–7.20]; p = 0.008) and 90-day mortality (2.69 [1.26–5.78]; p = 0.01) in multivariate regression analyses and improved reclassification in patients with septic shock, as assessed by the net reclassification index. Randomized albumin administration did not influence the associations between secretoneurin and outcomes. Conclusions: Secretoneurin provides early and potent prognostic information in septic patients with cardiovascular instability. 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). A complete list of centers and investigators participating in the Albumin Italian Outcome Sepsis substudy has been published elsewhere: Masson S, Caironi P, Spanuth E, et al; ALBIOS Study Investigators: Presepsin (soluble CD14 subtype) and procalcitonin levels for mortality prediction in sepsis: Data from the Albumin Italian Outcome Sepsis trial. Crit Care 2014; 18:R6. The Albumin Italian Outcome Sepsis trial was funded by a grant from the Agenzia Italiana del Farmaco (AIFA) (grant FARM6JS3R5, 2006). This project was also funded by Akershus University Hospital, the Research Council of Norway, the University of Oslo, and the South-Eastern Norway Regional Health Authority. Supported, in part, by funding from the Italian Ministry of Health (Ricerca Finalizzata, grant number RF-2011-02348358). Roche Diagnostics (Rotkreuz, Switzerland) provided in kind reagents for measuring N-terminal pro B-type natriuretic peptide and high-sensitive cardiac troponin T. Dr. Røsjø received personal fees from Novartis and CardiNor AS. Dr. Røsjø disclosed that this project was funded by Akershus University Hospital, the Research Council of Norway, the University of Oslo, and the South-Eastern Norway Regional Health Authority. Roche Diagnostics (Rotkreuz, Switzerland) provided in kind reagents for measuring N-terminal pro B-type natriuretic peptide and high sensitive cardiac troponin T. Dr. Røsjø has financial interests in CardiNor AS, which holds the license to commercialize secretoneurin. Drs. Masson’s and Caironi’s institutions received funding from the AIFA (grant FARM6JS3R5, 2006) and the Italian Ministry of Health (Ricerca Finalizzata, grant number RF-2011-02348358). Dr. Caironi received funding from Bbraun (lecture honoraria), Grifols (lecture honoraria and grant: Albumin Awards Program Grifols Award), and Ortho Diagnostic (lecture honoraria). Dr. Stridsberg received personal fees from CardiNor AS. Drs. Røsjø, Stridsberg, and Omland are partners in a patent filed by the University of Oslo regarding the use of secretoneurin as a biomarker in patients with cardiovascular disease and patients with critical illness. Dr. Christensen disclosed that he is a partner in a patent filed by the University of Oslo regarding the use of secretoneurin as a biomarker in patients with cardiovascular disease and patients with critical illness and has financial interests in CardiNor AS, which holds the license to commercialize secretoneurin. Dr. Urbano received support for article research from the National Institutes of Health and disclosed work for hire. Dr. Gattinoni received funding from Grifols (jury member for Albumin Grifols Award) and expert testimony in legal trials. Dr. Pesenti’s institution received funding from AIFA Official Italian agency for drug safety and studies, and he received funding from Xenios and Baxter. Dr. Omland’s institution received funding from Akershus University Hospital, Research Council of Norway, University of Oslo, and the South-Eastern Norway Regional Health Authority, and he received funding from Roche Diagnostics, Abbott Diagnostics, Bayer, Novartis, and CardiNor. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Helge Røsjø, MD, PhD, Division of Medicine, Akershus University Hospital, Sykehusveien 25, 1478 Lørenskog, Norway. E-mail: helge.rosjo@medisin.uio.no Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2oqAwib

The Impact of Hospital and Patient Factors on the Emergency Department Decision to Admit

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2
Author(s): Leah S. Honigman Warner, Jessica E. Galarraga, Ori Litvak, Samuel Davis, Michael Granovsky, Jesse M. Pines
BackgroundSubstantial variation exists in rates of emergency department (ED) admission. We examine this variation after accounting for local and community characteristics.ObjectivesElucidate the factors that contribute to admission variation that are amenable to intervention with the goal of reducing variation and health care costs.MethodsWe conducted a retrospective cross-sectional study of 1,412,340 patient encounters across 18 sites from 2012–2013. We calculated the adjusted hospital-level admission rates using multivariate logistic regression. We adjusted for patient, provider, hospital, and community factors to compare admission rate variation and determine the influence of these characteristics on admission rates.ResultsThe average adjusted admission rate was 22.9%, ranging from 16.1% (95% confidence interval [CI] 11.5–22%) to 32% (95% CI 26.0–38.8). There were higher odds of hospital admission with advancing age, male sex (odds ratio [OR] 1.20, 95% CI 1.91–1.21), and patients seen by a physician vs. mid-level provider (OR 2.26, 95% CI 2.23–2.30). There were increased odds of admission with rising ED volume, at academic institutions (OR 2.23, 95% CI 2.20–2.26) and at for-profit hospitals (OR 1.15, 95% CI 1.12–1.18). Admission rates were lower in communities with a higher per capita income, a higher rate of uninsured patients, and in more urban hospitals. In communities with the most primary providers, there were lower odds of admission (OR 0.60, 95% CI 0.57–0.68).ConclusionVariation in hospital-level admission rates is associated with a number of local and community characteristics. However, the presence of persistent variation after adjustment suggests there are other unmeasured variables that also affect admission rates that deserve further study, particularly in an era of cost containment.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EOJwrH

ENVIRONMEDICS. LEMERY JM, AND AUERBACH PS. LANHAM, MARYLAND, ROWMAN & LITTLEFIELD PUBLISHING GROUP, 2017:214. $33.

Publication date: Available online 23 February 2018
Source:The Journal of Emergency Medicine
Author(s): Edward J. Otten




from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EPbbVB

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

Publication date: Available online 23 February 2018
Source:The Journal of Emergency Medicine
Author(s): Jessica M. Hyams, Matthew J. Streitz, Joshua J. Oliver, Richard M. Wood, Yevgeniy M. Maksimenko, Brit Long, Robert M. Barnwell, Michael D. April
BackgroundChest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful.ObjectiveTo compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway).MethodsWe conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts.ResultsThe admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7–68.2%), vs. 48.3% (95% CI 43.7–53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7–21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33–0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE.ConclusionsThe HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EKDynF

Partial Contents of Volume 54, Number 3

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2





from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2nR3qaj

Predictor of Isolated Trauma in Head: A New Simple Predictor for Survival of Isolated Traumatic Brain Injury

Publication date: Available online 23 February 2018
Source:The Journal of Emergency Medicine
Author(s): Soo Hoon Lee, Daesung Lim, Dong Hoon Kim, Seong Chun Kim, Tae Yun Kim, Changwoo Kang, Jin Hee Jeong, Yong Joo Park, Sang Bong Lee, Rock Bum Kim
BackgroundMortality prediction in patients with brain trauma during initial management in the emergency department (ED) is essential for creating the foundation for a better prognosis.ObjectiveThis study aimed to create a simple and useful survival predictive model for patients with isolated blunt traumatic brain injury that is easily available in the ED.MethodsThis is a retrospective study based on the trauma registry data of an academic teaching hospital. The inclusion criteria were age ≥ 15 years, blunt and not penetrating mechanism of injury, and Abbreviated Injury Scale (AIS) scores between 1 and 6 for head and 0 for all other body parts. The primary outcome was 30-day survival probability. Internal and external validation was performed.ResultsAfter univariate logistic regression analysis based on the derivation cohort, the final Predictor of Isolated Trauma in Head (PITH) model for survival prediction of isolated traumatic brain injury included Glasgow Coma Scale (GCS), age, and coded AIS of the head. In the validation cohort, the area under the curve of the PITH score was 0.970 (p < 0.0001; 95% confidence interval 0.960–0.978). Sensitivity and specificity were 95% and 81.7% at the cutoff value of 0.9 (probability of survival 90%), respectively.ConclusionsThe PITH model performed better than the GCS; Revised Trauma Score; and mechanism of injury, GCS, age, and arterial pressure. It will be a useful triage method for isolated traumatic brain injury in the early phase of management.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FpyypG

Mumps: An Emergency Medicine-Focused Update

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2
Author(s): Chelsea Bockelman, Thomas C. Frawley, Brit Long, Alex Koyfman
BackgroundMumps is a Paramyxoviridae virus. This disease was rampant prior to introduction of the measles, mumps, and rubella vaccine, resulting in decreased incidence. This disease has demonstrated several outbreaks.ObjectiveThis review provides a focused evaluation of mumps, an update on outbreaks, management recommendations, and ways to decrease transmission.DiscussionClusters of mumps outbreaks continue to occur. The virus is a paramyxovirus, a single-stranded RNA virus. The vaccine can provide lifelong immunity if administered properly, though prior to 1967 and introduction of the vaccine, the virus was common. In the past decade, there have been several notable outbreaks. Humans are the only known hosts, with disease spread through exposure to droplets and saliva. Factors affecting transmission include age, compromised immunity, time of year, travel, and vaccination status. Upper respiratory symptoms, fever, and headache are common, with unilateral or bilateral parotitis, and the virus may spread to other systems. Diagnosis is clinical, though polymerase chain reaction and immunoglobulin testing are available. This review provides several recommendations for vaccine in pregnancy, patients living in close quarters, health care personnel, and those immunocompromised. Treatment is generally supportive, with emphasis on proper isolation to prevent widespread outbreaks. Although reporting regulations and procedures vary by state, mumps is reportable in most states.ConclusionsMumps is an easily spread virus. Although vaccination is the most effective way to prevent transmission, early recognition of the disease is crucial. As an emergency physician, it is important to recognize the clinical presentation, recommended testing, treatment, and isolation procedures.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2nOCV5g

Burnout Syndrome: Global Medicine Volunteering as a Possible Treatment Strategy

Publication date: Available online 19 February 2018
Source:The Journal of Emergency Medicine
Author(s): Kenneth V. Iserson
BackgroundIn the last few decades, “burnout syndrome” has become more common among clinicians, or at least more frequently recognized. Methods to prevent and treat burnout have had inconsistent results. Simultaneously, clinicians' interest in global medicine has increased dramatically, offering a possible intervention strategy for burnout while providing help to underserved areas.DiscussionCaused by a variety of stressors, burnout syndrome ultimately results in physicians feeling that their work no longer embodies why they entered the medical field. This attitude harms clinicians, their patients and colleagues, and society. Few consistently successful interventions exist. At the same time, clinicians' interest in global medicine has risen exponentially. This paper reviews the basics of both phenomena and posits that global medicine experiences, although greatly assisting target populations, also may offer a strategy for combating burnout by reconnecting physicians with their love of the profession.ConclusionsBecause studies have shown that regular volunteering improves mental health, short-term global medicine experiences may reinvigorate and reengage clinicians on the verge of, or suffering from, persistent burnout syndrome. Fortuitously, this intervention often will greatly benefit medically underserved populations.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2oaNOzt

Early Goal-Directed Therapy is Standard Therapy for Septic Shock

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2
Author(s): Joseph Shiber




from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BOZ63Z

Right Lower Quadrant Abdominal Pain: Do Not Forget About Ovarian Torsion on the Computed Tomography Scan

Publication date: Available online 17 February 2018
Source:The Journal of Emergency Medicine
Author(s): William Shyy, Roneesha S. Knight, Nathan A. Teismann
BackgroundAbdominal pain is one of the most common chief complaints of patients presenting to emergency departments, and emergency physicians (EPs) often evaluate patients with right lower quadrant abdominal pain. Ovarian torsion is a rare cause of abdominal pain, but early diagnosis is essential for salvage of the affected ovary. The diagnostic study of choice for ovarian torsion is a pelvic ultrasound with color Doppler, but it is important for EPs and radiologists to be aware of findings of ovarian torsion that might appear on computed tomography (CT).Case ReportWe present a case of a young female with right lower quadrant abdominal pain with CT evidence of ovarian torsion that was not recognized; the patient was discharged and then called back when the study was over-read as concerning for ovarian torsion.Why Should an Emergency Physician Be Aware of This?The presence of radiographic findings associated with ovarian torsion on a CT scan should encourage an EP to order a pelvic ultrasound with color Doppler (if available) and obtain an obstetrics/gynecology consult.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2oe7EZG

Noninvasive Ventilation as a Temporizing Measure in Critical Fixed Central Airway Obstruction: A Case Report

Publication date: Available online 23 February 2018
Source:The Journal of Emergency Medicine
Author(s): Lenard Tai Win Cheng, Tiong Beng Sim, Win Sen Kuan
BackgroundCritical central airway obstruction (CAO) requires emergent airway intervention, but current guidelines lack specific recommendations for airway management in the emergency department (ED) while awaiting rigid bronchoscopy. There are few reports of the use of noninvasive ventilation (NIV) in tracheomalacia, but its use as a temporizing treatment option in fixed, malignant CAO has not, to the best of our knowledge, been reported.Case ReportAn 84-year-old woman presented to the ED in respiratory distress, too breathless to speak and using her accessory muscles of respiration, with bilateral rhonchi throughout the lung fields. Point-of-care arterial blood gas revealed severe hypercapnia, and NIV was initiated to treat a presumed bronchitis with hypercapnic respiratory failure. Chest radiography revealed a paratracheal mass with tracheal deviation and compression. A diagnosis of critical CAO was made. While arranging for rigid bronchoscopic stenting, the patient was kept on NIV to good effect.Why Should an Emergency Physician Be Aware of This?Recommendations for emergent treatment of life-threatening, critical CAO before bronchoscopic intervention are not well established. Furthermore, reports of NIV use in CAO are rare. We suggest that emergency physicians consider NIV as a temporizing measure for critical CAO while awaiting availability of bronchoscopy.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2FqxF0c

Successful Interprofessional Approach to Development of a Resuscitative Endovascular Balloon Occlusion of the Aorta Program at a Community Trauma Center

Publication date: Available online 16 February 2018
Source:The Journal of Emergency Medicine
Author(s): Zaffer Qasim, Kevin Bradley, Heather Panichelli, Josie Robinson, Susan Coffey Zern
BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a relatively innovative procedure designed to control critical non-compressible torso hemorrhage. In the United States, this procedure is currently in active use at only a small number of trauma centers.ObjectiveWe describe how we developed our REBOA program at an independent academic-affiliated community trauma center.DiscussionThrough a close interprofessional and multidisciplinary collaboration led by emergency physicians and trauma surgeons, we were able to successfully develop our program.ConclusionsSuccessful implementation of a REBOA program requires close attention to multimodal training, interprofessional roles, team dynamics, financial considerations, and quality assurance processes to safely deliver this potentially life-saving procedure to our trauma patient population.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2GjZFBH

What is the Role of Reversal Agents in the Management of Emergency Department Patients with Dabigatran-Associated Hemorrhage?

Publication date: Available online 15 February 2018
Source:The Journal of Emergency Medicine
Author(s): Bryan D. Hayes, Michael E. Winters, Steve B. Rosenbaum, Mohannad F. Allehyani, Gary M. Vilke
BackgroundIn 2010, the U.S. Food and Drug Administration (FDA) approved dabigatran as the first non-warfarin oral anticoagulant for use in the United States. At the time of FDA approval, there was no antidote or effective treatment for dabigatran-induced hemorrhage. In 2015, the FDA approved idarucizumab for the treatment of dabigatran-induced hemorrhage. The purpose of this clinical practice statement is to evaluate the role of select reversal agents in the management of patients with dabigatran-associated bleeding.MethodsA PubMed literature review was completed to identify studies that investigated the role of reversal agents in the management of emergency department patients with dabigatran-associated hemorrhage. Articles included were those published in the English language between January 2010 and January 2017, enrolled human subjects, and limited to the following types: randomized controlled trials, prospective trials, meta-analyses, and retrospective cohort studies. Review articles, case series, and case reports were not included in this review. All selected articles then underwent a structured review by the authors.ResultsSix hundred fifty-two articles were identified in the search. After use of predetermined inclusion and exclusion criteria, six articles were selected for structured review.ConclusionThe clinical efficacy of activated prothrombin complex concentrates, idarucizumab, and recombinant factor VIIa remains unclear until further research is performed. Activated prothrombin complex concentrates, idarucizumab, and recombinant factor VIIa may be considered in patients with serious bleeding from dabigatran, after careful consideration of possible benefits and risks.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BvHWbp

Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2
Author(s): Tara Liberman, Andrzej Kozikowski, Nancy Kwon, Brian Emmert, Meredith Akerman, Renee Pekmezaris
BackgroundThe emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease.ObjectivesTo investigate the effectiveness of our AI Management program in the ED on key outcomes.MethodsWe conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate.ResultsOur sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001).ConclusionsThe ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2h50qV5

Low-Dose Propofol for Pediatric Migraine: A Prospective, Randomized Controlled Trial

Publication date: Available online 15 February 2018
Source:The Journal of Emergency Medicine
Author(s): David C. Sheridan, Matthew L. Hansen, Amber L. Lin, Rongwei Fu, Garth D. Meckler
BackgroundMigraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS).ObjectiveThe objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment.MethodsWe conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7–19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6–10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions.ResultsSeventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01).ConclusionsLDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BZqQUt

Interphysician Differences in Emergency Department Length of Stay

Publication date: Available online 15 February 2018
Source:The Journal of Emergency Medicine
Author(s): Stephen J. Traub, Soroush Saghafian, Kurtis Judson, Christopher Russi, Bo Madsen, Stephen Cha, Hannah C. Tolson, Leon D. Sanchez, Jesse M. Pines
BackgroundEmergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).ObjectiveTo describe how ED LOS differs among physicians.MethodsWe performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOSO/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year.ResultsThree hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106–184 min), and the average longest observed LOS was 232 min (range 196–270 min); the average difference was 81 min (range 69–90 min). For LOSO/E, the average lowest LOSO/E was 0.801 (range 0.702–0.887), and the average highest LOSO/E was 1.210 (range 1.186–1.275); the average difference between the lowest LOSO/E and the highest LOSO/E was 0.409 (range 0.305–0.493).ConclusionThere are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOSO/E for physicians with the lowest LOSO/E at each site averaged approximately 20% less than predicted, and that the LOSO/E for physicians with the highest LOSO/E at each site averaged approximately 20% more than predicted.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2swBo9B

Approach to a Patient with Diplopia in the Emergency Department

Publication date: Available online 14 February 2018
Source:The Journal of Emergency Medicine
Author(s): Edward Margolin, Cindy T.Y. Lam
BackgroundDiplopia can be the result of benign or life-threatening etiologies. It is imperative for the emergency physician to be proficient at assessing diplopia and recognize when urgent referral or neuroimaging is required.ObjectiveThe first part of this review highlights a simple framework to arrive at the appropriate disposition of diplopic patients presenting to the emergency department (ED). The second part of this review provides more detail and further management strategies.DiscussionED strategies for assessment of diplopia are discussed. Management strategies, such as when to image, what modality of imaging to use, and urgency of referral, are discussed in detail.ConclusionsUnenhanced plain computed tomography (CT) of the head or orbits is largely not useful in the work-up of diplopia. Magnetic resonance imaging is preferred for ocular motor nerve palsies. Due to limited resources in the ED, patients with isolated fourth and sixth nerve palsies with the absence of other neurological signs on examination should be referred to Neurology or Ophthalmology for further work-up. All patients presenting with an acute isolated third nerve palsy should be imaged with CT and CT angiography of the brain to rule out a compressive aneurysm. Contrast-enhanced CT imaging of the brain and orbits would be indicated in suspected orbital apex syndrome or a retro-orbital mass, thyroid eye disease, or ocular trauma. CT and CT venogram should be considered in cases of suspected cavernous sinus thrombosis. In any patient over the age of 60 years presenting with recent (1 month) history of diplopia, inflammatory markers should be obtained to rule out giant cell arteritis.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BuPX0n

Recommendations for Treatment with Neuraminidase Inhibitors in Emergency Department Patients Infected with Influenza Virus

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2
Author(s): Adam S. Bloom, John J. Devlin, Sanaz B. Devlin




from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2EQFfEo

Traumatic Lingual Hematoma Resulting in Bilateral Temporal Mandibular Joint Dislocations

Publication date: Available online 13 February 2018
Source:The Journal of Emergency Medicine
Author(s): Dhara P. Amin, Michael N. Cooper, Kim I. Newton
BackgroundLingual hematoma (LH) is a relatively uncommon entity seen after both medical and traumatic etiologies. Regardless of the cause, the feared complication is acute airway obstruction.Case ReportOur case involves a 39-year-old man who presented to the Emergency Department via emergency medical services with an enlarging LH after an unwitnessed fall, suspected to be an alcohol withdrawal seizure. The bleeding was likely exacerbated by previously undiagnosed thrombocytopenia. Airway stabilization was rapidly established via nasotracheal intubation after standard intubation techniques were deemed unfeasible. Despite correction of the coagulopathy, the LH continued to expand, resulting in bilateral tympanomandibular joint (TMJ) dislocations. To our knowledge, this complication has not been previously reported as a complication of LH.Why Should an Emergency Physician Be Aware of This?Despite being a relatively uncommon condition, LH has the potential to result in life-threatening airway obstruction with limited airway options. Prompt airway stabilization should be the first priority upon diagnosis. A rapidly evolving LH can limit standard orotracheal rapid sequence intubation options, and may require alternative airway procedures. Additionally, ongoing lingual swelling after airway stabilization has now been shown in our case to result in bilateral TMJ dislocations. Concurrent management of reversible coagulopathy may help prevent this complication or reduce its severity.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2C1axq0

American Academy of Emergency Medicine

Publication date: February 2018
Source:The Journal of Emergency Medicine, Volume 54, Issue 2





from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2nJZVU2

Disaster Training in 24 Hours: Evaluation of a Novel Medical Student Curriculum in Disaster Medicine

Publication date: Available online 13 February 2018
Source:The Journal of Emergency Medicine
Author(s): Lauren Wiesner, Shane Kappler, Alex Shuster, Michael DeLuca, James Ott, Eric Glasser
BackgroundOver a decade ago, the Association of American Medical Colleges called for incorporation of disaster medicine training into the education of medical students in the United States. Despite this recommendation, similar suggestions by other professional organizations, and significant interest from medical students and educators, few medical schools explicitly include robust disaster training in their curricula.ObjectivesThis study describes the results of the implementation of a novel medical student curriculum in disaster response at an allopathic U.S. medical school. Specifically, this study evaluates the effectiveness of a voluntary training program in increasing the knowledge of medical students to respond to disasters.MethodsOver 2 years, 24 hours of training consisting of didactics and hands-on exercises was delivered to medical students by volunteers from the Department of Emergency Medicine. Student knowledge was tested prior to and after each training session through a multiple-choice questionnaire and evaluated using a paired t-test.ResultsConsistent with previous studies, this voluntary disaster curriculum improved students' knowledge of emergency preparedness. The mean test score for all students participating in the training increased from 5.30 ± 1.05 (with a maximum score of 10), to 7.98±0.96 post course.ConclusionThis intervention represents a low-cost, high-impact mechanism for improving the capacity of an underutilized segment of the health care team to respond to public health emergencies.



from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2BwfRB0