The organization of Danish emergency departments

Introduction Twenty-one new Danish emergency departments (EDs) were established following a 2007 policy reform that included ED autonomy to self-organize. The aim of this study was to describe the organization of the 21 departments and their organizational challenges. Participants and methods We used a qualitative design based on COREQ guidelines. All 21 EDs participated, and 123 semi-structured interviews with hospital and ED leaders, physicians, nurses, and secretaries were performed between 2013 and 2015. We used the framework matrix method to investigate the ED goals, setting, structure, staff, task coordination, and incentive structure. Results We identified three generic models (virtual, hybrid, and independent). All had goals of high quality of care and high efficiency. The virtual model was staffed by junior physicians and tasks were coordinated by other departments. The hybrid model was staffed by junior physicians and senior physicians according to other departments and the ED. The ED coordinated all activities. The independent model was staffed by junior physicians and senior physicians, and activities were coordinated by the ED. Of the EDs, 19 utilized different organizational models at different times during a 24-h period and on weekdays and weekends. The main challenge of the virtual and hybrid models was high dependency on other departments. The main challenge of the independent model was establishing a high level of quality of emergency medicine. Discussion and conclusion We identified three organizational ED models (virtual, hybrid, and independent). Nineteen EDs used more than one organizational model depending on the time of day or day of the week. Correspondence to Anders Moellekaer, MD, MBA, Research Center for Emergency Medicine, Aarhus University Hospital, Noerrebrogade 44, Bygning 30, 1. sal, DK-8000 Aarhus, Denmark Tel: +45 20 848 304; e-mail: anders.moellekaer@ki.au.dk Received January 7, 2017 Accepted April 13, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Prevention of Nosocomial Infections in Critically Ill Patients With Lactoferrin: A Randomized, Double-Blind, Placebo-Controlled Study

Objective: To obtain preliminary evidence for the efficacy of lactoferrin as a preventative measure for nosocomial infections and inform the conduct of a definitive study. Design: Phase 2, multicenter, randomized, double-blind, placebo-controlled study. Setting: Medical-surgical ICUs. Patients: Adult, critically ill patients receiving invasive mechanical ventilation. Interventions: Randomized, eligible, consenting patients expected to require invasive mechanical ventilation more than 48 hours received lactoferrin both enterally and via an oral swab or a placebo of sterile water for up to 28 days. Measurements and Main Results: Of the 214 patients who were randomized, 212 received at least one dose of the intervention and were analyzed (107 lactoferrin and 105 placebo). Protocol adherence was 87.5%. Patients receiving lactoferrin were older (mean [SD], 66.3 [13.5] vs 62.5 [16.2] yr), had a higher Acute Physiology and Chronic Health Evaluation II score (26.8 [7.8] vs 23.5 [7.9]), and need for vasopressors (79% vs 70%). Antibiotic-free days (17.3 [9.0] vs 18.5 [7.1]; p = 0.91) and nosocomial infections (0.3 [0.7] vs 0.4 [0.6] per patient; p = 0.48) did not differ between lactoferrin and placebo groups, respectively. Clinical outcomes for lactoferrin versus placebo were as follows: ICU length of stay (14.5 [18.0] vs 15.0 [37.3] d; p = 0.82), hospital length of stay (25.0 [25.9] vs 28.1 [44.6] d; p = 0.57), hospital mortality (41.1% vs 30.5%; p = 0.11), and 90-day mortality (44.9% vs 32.4%; p = 0.06). Biomarker levels did not differ between the groups. Conclusions: Lactoferrin did not improve the primary outcome of antibiotic-free days, nor any of the secondary outcomes. Our data do not support the conduct of a larger phase 3 trial. The study was conceptualized by Dr. Muscedere. All authors contributed to the conduct of the study and/or provided input on the article. 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 (https://ift.tt/29S62lw). Supported, in part, by grants from the Lotte and John Hecht Memorial Foundation and South Eastern Academic Medical Association. The bovine lactoferrin was provided by Advanced Orthomolecular Research. The funders did not have any role in the conceptualization, conduct of the study, study analysis, interpretation of the data, or writing of the article. Dr. Muscedere, Dr. Maslove, Dr. Boyd, Ms. O’Callaghan, Dr. Reynolds, Dr. Hall, and Dr. Jones disclosed off-label product use of lactoferrin for the reduction of nosocomial infections. Dr. Boyd’s institution received funding from South Eastern Academic Medical Association (SEAMO) Innovation Fund and SEAMO New Clinician Scientist Award, and he received funding from Physician Services Incorporated New Clinician Science Award. Dr. Hall’s institution received funding from Queen’s University, Canadian Institutes for Health Research, and GlaxoSmithKline. Mr. Day’s institution received funding from Queen’s University Faculty of Health Sciences to Kingston General Hospital Research Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: muscedej@kgh.kari.net Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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A Case for Change in Adult Critical Care Training for Physicians in the United States: A White Paper Developed by the Critical Care as a Specialty Task Force of the Society of Critical Care Medicine

Objectives: In the United States, physician training in Critical Care Medicine has developed as a subspecialty of different primary boards, despite significant commonality in knowledge and skills. The Society of Critical Care Medicine appointed a multidisciplinary Task Force to examine alternative approaches for future training. Design: The Task Force reviewed the literature and conducted informal discussions with key stakeholders. Specific topics reviewed included the history of critical care training, commonalities among subspecialties, developments since a similar review in 2004, international experience, quality patient care, and financial and workforce issues. Main Results: The Task Force believes that options for future training include establishment of a 1) primary specialty of critical care; 2) unified fellowship and certification process; or 3) unified certification process with separate fellowship programs within the current specialties versus 4) maintaining multiple specialty-based fellowship programs and certification processes. Conclusions: 1) Changing the current Critical Care Medicine training paradigms may benefit trainees and patient care. 2) Multiple pathways into critical care training for all interested trainees are desirable for meeting future intensivist workforce demands. 3) The current subspecialties within separate boards are not “distinct and well-defined field[s] of medical practice” per the American Board of Medical Specialties. Recommendations for first steps are as follows: 1) as the society representing multidisciplinary critical care, the Society of Critical Care Medicine has an opportunity to organize a meeting of all stakeholders to discuss the issues regarding Critical Care Medicine training and consider cooperative approaches for the future. 2) A common Critical Care Medicine examination, possibly with a small percentage of base-specialty–specific questions, should be considered. 3) Institutions with multiple Critical Care Medicine fellowship programs should consider developing joint, multidisciplinary training curricula. 4) The boards that offer Critical Care Medicine examinations, along with national critical care societies, should consider ways to shorten training time. Drs. Tisherman and Spevetz are Co-Chair persons. 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 (https://ift.tt/29S62lw). Supported, in part, by the Society of Critical Care Medicine. Dr. Tisherman has disclosed that he represents the Society of Critical Care Medicine (SCCM) on the Trauma, Burns, and Critical Care Board of the American Board of Surgery, and he is also President of the Surgical Critical Care Program Directors Society. Dr. Spevetz has disclosed that she serves as the SCCM representative to the American Board of Internal Medicine (ABIM) Liaison committee on Certification and Recertification. Dr. Brown serves as an examiner for the American Board of Anesthesiology. Dr. Chang received funding from SCCM (Council Member; financial relationship related only to reimbursement for travel expenses and complimentary registration for the annual congress; no honoraria), the Neurocritical Care Society (Past-President; nonvoting, ex-officio member of the Board of Directors; financial relationship limited to travel expenses to stand-alone Board meetings; no honoraria), ABIM Critical Care Medicine Certification Examination Writing Committee (current member, travel expenses and honorarium), and received reimbursement for travel and honoraria for lectures at annual meetings from the American College of Physicians, and from the Indonesian SCCM for a Multiprofessional Critical Care Review Course for Continuing Education Program for their membership. She also disclosed that she was the Co-Chair (Past/Inaugural Chair) for the Neurocritical Care Examination Writing Committee of the United Council of Neurological Subspecialties and the Certification Committee for the Neurocritical Care Society. Dr. O’Connor received funding from CLEW (previously known as Intensix; scientific advisory board). Dr. Sevransky’s institution received funding from the Marcus Foundation, and he received funding from SCCM (Associate Editor stipend). He is an associate editor of Critical Care Medicine. Dr. Wessman is the Program Director for the Anesthesiology Critical Care Medicine Fellowship at Washington University of St. Louis and the Chair of the SCCM Emergency Medicine Section. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: stisherman@umm.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study

Objectives: Many septic patients receive care that fails the Centers for Medicare and Medicaid Services’ SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the “all-or-nothing” measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented. Design: Retrospective cohort study. Setting: Seven U.S. hospitals. Patients: Adult patients included in SEP-1 reporting between October 2015 and September 2017. Interventions: None. Measurements and Main Results: Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p

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Effects of dispatcher-assisted bystander cardiopulmonary resuscitation on neurological recovery in paediatric patients with out-of-hospital cardiac arrest based on the pre-hospital emergency medical service response time interval

Resuscitation

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Acute kidney injury is common with intravenous abuse of extended-release oral oxymorphone and delayed renal recovery rates are associated with increased KDIGO staging

Nephrology

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EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David Story

Bicar-ICU changes my practice with bicarb infusions and let's end the great lactate debate on EMCrit 227:

EMCrit Project by Scott Weingart.

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EMCrit Podcast – Acid Base Ep. 7 – Bicarb Updates, Quantitative Approach, and Prof. David Story

Bicar-ICU changes my practice with bicarb infusions and let's end the great lactate debate on EMCrit 227:

EMCrit Project by Scott Weingart.

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Shark related injuries: A case series of Emergency Department patients

The American Journal of Emergency Medicine

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Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study

Resuscitation

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Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: A multicentre prospective observational study

Resuscitation

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Characteristics of fall-related traumatic brain injury in older adults

Internal Medicine Journal

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Severity of button batteries ingestions: data from French Poison Control Centres between 1999 and 2015

Background Although the ingestion of button batteries is an infrequent situation, it leads to a significant risk of causing serious damage. Objective This study was carried out to describe all the cases of button battery ingestion recorded by the French Poison Control Centers over 16 years. Patients and methods All the cases of button battery ingestion were recorded from 1 January 1999 to the end of June 2015, analysed (age, sex, number of ingested button batteries, clinical signs and treatments) and graded for severity according to the poisoning severity score. Results The incidence of button batteries ingestions was constant over the 16-year period, with an average of 266±98.5 cases per year and a total of 4030 cases. Nevertheless, 21 cases were severe and two deaths occurred. Interestingly, for the two patients who died, the battery was stuck in the oesophagus and they presented anorexia and/or dysphagia, abdominal pain and fever and in one case, a melena 3 weeks after ingestion. Importantly, these symptoms were observed even if the battery was expelled in one fatal case. Conclusion Ingestions of button batteries still occur and may cause serious damage, especially in children, and if the button battery is stuck in the oesophagus as it might cause severe symptoms. Patients who have ingested a button battery must be directed to the emergency department for medical evaluation, even if the button battery has been expelled from the body and even more if gastrointestinal symptoms are present.

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Can an age-adjusted D-dimer level be adopted in managing venous thromboembolism in the emergency department? A retrospective cohort study

Introduction Patients suspected of having venous thromboembolism (VTE), with a low pretest probability, undergo D-dimer testing. A negative D-dimer, in a low-risk patient rules out VTE with a high degree of certainty because of its high sensitivity. It is, however, a poorly specific test, and the absolute value increases with age. The aim of this study was to establish whether an age-adjusted D-dimer could be safely used instead of a standard cut-off level in low-risk patients over the age of 50 years. Patients and methods This was a retrospective review of 1649 patients with suspected VTE whose D-dimer levels were analysed. In low-risk patients (defined as ‘VTE unlikely’ using the dichotomized Wells’ scores), the outcomes in terms of confirmed VTE diagnosis, hospital admission and investigations using an age-adjusted D-dimer level (measured in D-dimer units) of 5× the age for patients over 50 years of age and 250 ng/ml for patients younger than 50 years of age, was compared with the cut-off standard level (230 ng/ml in all patients). Results Of the total group of patients in the VTE unlikely group, the proportion of patients with a negative D-dimer when using the standard cut-off was 64.9% (859/1324). A further 130 patients had a negative D-dimer when the age-adjusted cut-off was used, increasing the proportion of all patients in whom VTE could be excluded without imaging to 74.7% (989/1324). For those patients of 75 years or older, the proportion of patients in whom VTE could be excluded without imaging increased from only 91/242 (37.6%) when using the standard D-dimer cut-off to 154/242 (63.6%) when the age-adjusted cut-off was used. These changes occurred without any additional false-negative findings. Conclusion For patients over the age of 50 years suspected of having VTE with a low pretest probability, increasing the D-dimer cut-off level to 5× the age increases the proportion of patients in whom VTE can safely be excluded without radiological imaging.

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Practical management of concomitant acute heart failure and worsening renal function in the emergency department

Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as ‘pseudo-WRF’ and should not detract clinicians from targeting ‘guideline-recommended’ therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.

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Characteristics of children with microbiologically confirmed invasive bacterial infections in the emergency department

Background Determination of the characteristics of paediatric invasive bacterial infections (IBI) is essential for early identification of children requiring immediate antibiotic therapy. The main objective is to characterize the emergency presentation of the IBI among children aged younger than 14 years. Patients and methods A prospective registry-based cohort study including all patients aged younger than 14 years diagnosed with confirmed IBI (culture or genomic detection using the polymerase chain reaction) was carried out in a paediatric emergency department between 2008 and 2015. Severity criteria were as follows: death, sequelae or admission to the ICU. Results Of the 223 IBIs reported, 187 (83.9%) corresponded to previously healthy patients (median age=19 months) and 165 (74%) were well appearing. The most common diagnoses were occult bacteraemia [60 (26.9%)] and sepsis [56 (25.1%)]. The most frequent pathogens were Streptococcus pneumoniae [68 (30.5%)] and Neisseria meningitidis [42 (18.8%)]. Four (1.8) patients died (S. pneumoniae, 2) and eight (3.5%) had sequelae (S. pneumoniae, 5). The diagnoses and clinical characteristics of the children varied significantly depending on the isolated pathogen. Duration of fever less than 24 h, symptoms other than fever and not being well-appearing upon arrival to the emergency department were independent risk factors for greater severity (area under the receiver operating characteristics curve=0.805; 95% confidence interval: 0.741–0.868). Conclusion IBIs are commonly diagnosed in previously healthy and well-appearing young children. S. pneumoniae was responsible for the majority of deaths or sequelae. Short duration of fever, symptoms other than fever and not being stable on arrival are associated with greater severity.

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A randomized-controlled trial of a patient-centred intervention in high-risk discharged older patients

Background The risk of early reattendance after discharge has been proposed as a performance indicator for emergency departments (EDs), but is not uniform in all patients. Those individuals at the highest risk of reattendance may benefit from an intense intervention to reduce this risk, and our objective was to test this hypothesis in a clinical trial. Methods A randomized-controlled trial was conducted in the EDs of two hospitals. Very high-risk adults aged 65 years and older, identified using a validated risk-prediction nomogram and being discharged from ED, were randomized to receive a postdischarge patient-centred intervention or standard care. The intervention focused on identifying and supporting patients to address risk factors for future hospital presentation. The primary outcome measure was any unplanned ED reattendance within 28 days. Secondary outcomes included 28-day and 1-year hospital usage, institutionalization and death. Results We enrolled 164 patients, 82 in each study arm. There was an 8% absolute (95% confidence interval: −7%–20%) and a 20% relative risk reduction for an intervention patient making an unplanned ED reattendance within 28 days. This difference was not statistically significant (P=0.26). Conclusion This postdischarge intervention was associated with only small and nonsignificant reductions in ED reattendance.

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The SPEED score in the emergency department: not so fast!

No abstract available

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Influences on emergency department length of stay for older people

Objective The aim of this study was to examine the influences on emergency department (ED) length of stay (LOS) for older people and develop a predictive model for an ED LOS more than 4 h. Methods This retrospective cohort study used organizational data linkage at the patient level from a major Australian health service. The study population was aged 65 years or older, attending an ED during the 2013/2014 financial year. We developed and internally validated a clinical prediction rule. Discriminatory performance of the model was evaluated by receiver operating characteristic (ROC) curve analysis. An integer-based risk score was developed using multivariate logistic regression. The risk score was evaluated using ROC analysis. Results There were 33 926 ED attendances: 57.5% (n=19 517) had an ED LOS more than 4 h. The area under ROC for age, usual accommodation, triage category, arrival by ambulance, arrival overnight, imaging, laboratory investigations, overcrowding, time to be seen by doctor, ED visits with admission and access block relating to ED LOS more than 4 h was 0.796, indicating good performance. In the validation set, area under ROC was 0.80, Hosmer–LemeshowP-value was 0.36 and prediction mean square error was 0.18, indicating good calibration. The risk score value attributed to each risk factor ranged from 2 to 68 points. The clinical prediction rule stratified patients into five levels of risk on the basis of the total risk score. Conclusion Objective identification of older people at intermediate and high risk of an ED LOS more than 4 h early in ED care enables targeted approaches to streamline the patient journey, decrease ED LOS and optimize emergency care for older people.

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Floruit EUSEM

No abstract available

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No more winter crisis? Forecasting daily bed requirements for emergency department admissions to hospital

Study hypothesis We hypothesized that age, calendar variables, and clinical influenza epidemics may have an impact on the number of daily through-emergency department (ED) hospitalizations. The aim of our study was to elaborate a pragmatic tool to predict the daily number of through-ED hospitalizations. Methods We carried out a prospective-observational study including data from 18 ED located in the Paris metropolitan area. Daily through-ED hospitalizations numbers from 2007 to 2010 were modelized to forecast the year 2011 using a general linear model by age groups (

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Crew Resource Management in the trauma room: a prospective 3-year cohort study

Objective Human factors account for the majority of adverse events. Human factors awareness training entitled Crew Resource Management (CRM) is associated with improved safety and reduced complications and mortality in critically ill patients. We determined the effects of CRM implementation in the trauma room of an Emergency Department (ED). Patients and methods A prospective 3-year cohort study was carried out in a level 1 ED, admitting more than 12 000 patients annually (>1500 trauma related). At the end of the baseline year, CRM training was performed, followed by an implementation year. The third year was defined as the clinical effect year. The primary outcomes were safety climate, measured using the Safety Attitudes Questionnaire, and ED length of stay. The secondary outcome measures were hospital length of stay and 48-h crude mortality of trauma patients. Results All 5070 trauma patients admitted to the ED during the study period were included. Following CRM implementation, safety climate improved significantly in three out of six Safety Attitudes Questionnaire domains, both at the end of the implementation and clinical effect years: teamwork climate, safety climate, and stress recognition. ED length of stay of these patients increased from 141 (102–192) in the baseline year to 161 (116–211) and 170 (128–223) min in the implementation and clinical effect years, respectively (P

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Which indicators to include in a crowding scale in an emergency department? A national French Delphi study

Background Emergency department (ED) crowding is a serious international public health issue with a negative impact on quality of care. Despite two decades of research, there is no consensus on the indicators used to quantify crowding. The aim of our study was to select the most valid ED crowding indicators. Materials and methods The Delphi method was used. Selected indicators originated from a literature review and propositions from FEDORU (National Emergency Department Observatory Network) workgroup. Selected national experts were emergency physicians with a special interest in ED crowding. They had to assess each indicator in terms of validity out of a Likert scale from 1 to 9. Indicators withdrawal criteria after each round (consensus) were over 70% of answers of at least 7 with interquartile range less than 3 (positive consensus) or over 70% of answers of at least 4 and interquartile range less than 3 (negative consensus). The decision to stop the delphi procedure was based on the stability of answers between the rounds. Results 41 (89.13%) experts answered the first round and 37 (80.43%) answered the second round. Among the 57 indicators included, 15 reached consensus: four input indicators, six throughput and five output ones. For those three categories of at least 7 answers rates were, respectively, 80.9, 76.9 and 75.0%. Five indicators were deducible from the mandatory Emergency Department Discharge Summary. They obtained 80.2% of at least 7 answers. Conclusion Our study results enable the construction and validation of a crowding measuring tool from indicators approved by experts. It is necessary to further reflect about ED crowding as a concept and what is expected from a complex score.

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Lessons learned in applying the International Society for Pharmacoeconomics and Outcomes Research methodology to translating Canadian Emergency Department Information System Presenting Complaints List into German

Objectives The patient’s presenting complaint guides diagnosis and treatment in the emergency department, but there is no classification system available in German. The Canadian Emergency Department Information System (CEDIS) Presenting Complaint List (PCL) is available only in English and French. As translation risks the altering of meaning, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) has set guidelines to ensure translational accuracy. The aim of this paper is to describe our experiences of using the ISPOR guidelines to translate the CEDIS PCL into German. Materials and methods The CEDIS PCL (version 3.0) was forward-translated and back-translated in accordance with the ISPOR guidelines using bilingual clinicians/translators and an occupationally mixed evaluation group that completed a self-developed questionnaire. Results The CEDIS PCL was forward-translated (four emergency physicians) and back-translated (three mixed translators). Back-translation uncovered eight PCL items requiring amendment. In total, 156 comments were received from 32 evaluators, six of which resulted in amendments. Conclusion The ISPOR guidelines facilitated adaptation of a PCL into German, but the process required time, language skills and clinical knowledge. The current methodology may be applicable to translating the CEDIS PCL into other languages, with the aim of developing a harmonized, multilingual PCL.

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Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study

Background The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process. Objective The aim of this study was to explore the inter-rater and test–retest reliability, and the rate of correct triage of the revised SETS. Patients and methods Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test–retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage. Results A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60–0.78] and test–retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84–0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20–1.39). Conclusion The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

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The SPEED score: give it some time

No abstract available

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Validity of the Pediatric Canadian Triage Acuity Scale in a tertiary children’s hospital in Israel

Objective In 2015, the Israeli Ministry of Health issued national guidelines demanding the use of a five-level triage system in pediatric emergency departments (EDs). The present study aimed to evaluate the validity of the Pediatric Canadian Triage Acuity Scale (PedCTAS) in the ED of a tertiary children’s hospital in Israel. Methods A retrospective cohort study of all patients admitted between January 2011 and December 2015 was carried out. The proportion of hospitalization was the primary outcome measure. The secondary outcomes were proportion of admissions to the ICU, proportions of patients who left without being seen (LWBS), and length of stay (LOS) in the ED. Results A total of 83 609 patients were included in our analysis. Triage levels 1–5 included 533 (0.6%), 4428 (5.3%), 46 461 (55.6%), 28 510 (34.1%), and 3677 (4.4%) patients, respectively. Hospitalization proportions were 70, 51, 28, 15, and 12% for triage levels 1, 2, 3, 4, and 5, respectively. Admission proportions to ICU were 24.2, 3.05, 0.24, 0.05, and 0.05% for PedCTAS levels 1, 2, 3, 4, and 5, respectively. The proportions of LWBS were 0.001, 0.002, and 0.005% for triage levels 3, 4, and 5, respectively. LOS was shorter as the triage level increased from 2 to 5. Conclusion Triage level was predictive of hospitalization, admission to the ICU, and proportions of LWBS and LOS in the ED. The findings suggest validity of the PedCTAS in this cohort. This is the first report of the performance of a triage tool in an Israeli ED.

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Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study)

Background Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR. Patients and methods From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire. Results A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P

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A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: An observational cohort study

Resuscitation

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Effects of prehospital epinephrine administration on neurologically intact survival in bystander-witnessed out-of-hospital cardiac arrest patients with non-shockable rhythm depend on prehospital cardiopulmonary resuscitation duration required to hospital arrival

Heart and Vessels

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Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study

The American Journal of Emergency Medicine

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Echocardiographic left ventricular diastolic dysfunction predicts hospital mortality after out-of-hospital cardiac arrest

Journal of Critical Care

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Hepatitis C among vulnerable populations: A seroprevalence study of homeless, people who inject drugs and prisoners in London

Journal of Viral Hepatitis

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Effect of hypertension across the age group on survival outcomes in out-of-hospital cardiac arrest

The American Journal of Emergency Medicine

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Single-use laundry detergent pack exposures in children under 6 years: A prospective study at U.S. Poison Control Centers

The Journal of Emergency Medicine

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PulmCrit: pH-guided fluid resuscitation & BICAR-ICU

The use of bicarbonate is a source of eternal disagreement.  Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest).  This has impugned its reputation, giving it an aura of ignorance and failure.  Consequently, bicarbonate is underutilized in some situations where it might actually help.

EMCrit Project by Josh Farkas.

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PulmCrit: pH-guided fluid resuscitation & BICAR-ICU

The use of bicarbonate is a source of eternal disagreement.  Bicarbonate has a shameful history of being abused in situations where it’s unhelpful (e.g. cardiac arrest).  This has impugned its reputation, giving it an aura of ignorance and failure.  Consequently, bicarbonate is underutilized in some situations where it might actually help.

EMCrit Project by Josh Farkas.

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Safety of the combination of PERC and YEARS rules in patients with low clinical probability of PE: a retrospective analysis of two large European cohorts

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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The role of point of care ultrasound in prehospital critical care: a systematic review

In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasib...

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Safety and tolerability of moxifloxacin in children

Journal of the Pediatric Infectious Diseases Society

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Risk factors of upper gastrointestinal hemorrhage with acute coronary syndrome: A nested case-control study

The American Journal of Emergency Medicine

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Impact of aura and status migrainosus on readmissions for vascular events after migraine admission

Headache: The Journal of Head and Face Pain

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A host-protein signature is superior to other biomarkers for differentiating between bacterial and viral disease in patients with respiratory infection and fever without source: A prospective observational study

European Journal of Clinical Microbiology & Infectious Diseases

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Emergency medicine physicians' ability to predict hospital admission at the time of triage

The American Journal of Emergency Medicine

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Mortality Risk Using a Pediatric Quick Sequential (Sepsis-Related) Organ Failure Assessment Varies With Vital Sign Thresholds

Objectives: We evaluated adapting the quick Sequential (Sepsis-Related) Organ Failure Assessment score (fast respiratory rate, altered mental status, low blood pressure) for pediatric use by selecting thresholds from three commonly used definitions: Pediatric Logistic Organ Dysfunction 2, Pediatric Advanced Life Support, and International Pediatric Sepsis Consensus Conference. We examined their respective performance in identifying children who had a discharge diagnosis of infection at high risk of mortality using PICU registry data, with additional focus on the influence of age on performance. Design: Analysis of retrospective data obtained from the Virtual Pediatric Systems PICU database. The performance in predicting observed mortality was assessed for the three candidate approaches using receiver operating characteristics analysis, including age group effects. Setting: The Virtual Pediatric Systems database contains data on diagnosis, clinical markers, and outcomes in prospectively collected clinical records from 130 participating PICUs in the United States and Canada. Patients: Children who had a discharge diagnosis of infection in a participating PICU between 2009 and 2014, for which all required data were available. Interventions: None. Measurements and Main Results: Data from 40,228 children revealed an overall mortality of 4.22%. Area under the receiver operating characteristics curve (95% CI) was 0.760 (0.749–0.771) for Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation, 0.700 (0.689–0.712) for Pediatric Advanced Life Support, and 0.709 (0.696–0.721) for International Pediatric Sepsis Consensus Conference. When split by age group, the performance of Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation was lowest in the youngest neonates (under 1 wk old), with an area under the receiver operating characteristics curve (95% CI) of 0.724 (0.656–0.791), and in the teenagers (13–18 yr), with an area under the receiver operating characteristics curve of 0.710 (0.682–0.738), yet it still outperformed Pediatric Advanced Life Support and International Pediatric Sepsis Consensus Conference in both groups. Conclusions: Among critically ill children who had a discharge diagnosis of infection in the PICU, quick Sequential (Sepsis-Related) Organ Failure Assessment score performs best when using the Pediatric Logistic Organ Dysfunction 2 age thresholds with mechanical ventilation, while all definitions performed worse at extremes of pediatric age. Thus, mortality risk varies with vital sign thresholds, and although Pediatric Logistic Organ Dysfunction 2 with mechanical ventilation performed marginally better, it is unlikely to be of use to clinicians. More work is needed to develop a robust and relevant pediatric sepsis risk score. 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 (https://ift.tt/2gIrZ5Y). Dr. Brant received support for article research from BC Children’s Hospital Research Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: cherylpeters@gmail.com ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Management of the Critically Ill Adult Chimeric Antigen Receptor-T Cell Therapy Patient: A Critical Care Perspective

Objectives: Chimeric antigen receptor T-cell therapy, a type of immune effector therapy for cancer, has demonstrated encouraging results in clinical trials for the treatment of patients with refractory hematologic malignancies. Nevertheless, there are toxicities specific to these treatments that, if not recognized and treated appropriately, can lead to multiple organ failure and death. This article is a comprehensive review of the available literature and provides, from a critical care perspective, recommendations by experienced intensivists in the care of critically ill adult chimeric antigen receptor T-cell patients. Data Sources: PubMed and Medline search of articles published from 2006 to date. Study Selection: Clinical studies, reviews, or guidelines were selected and reviewed by the authors. Data Extraction: Not available . Data Synthesis: Not available. Conclusions: Until modifications in chimeric antigen receptor T-cell therapy decrease their toxicities, the intensivist will play a leading role in the management of critically ill chimeric antigen receptor T-cell patients. As this novel immunotherapeutic approach becomes widely available, all critical care clinicians need to be familiar with the recognition and management of complications associated with this treatment. Drs. Gutierrez, McEvoy, Mead, Stephens, and Pastores disclosed off-label product use of siltuximab for use in cytokine release syndrome and neurotoxicity related to chimeric antigen receptor T cells. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: cgutierrez4@mdanderson.org Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Leak Compensation During Volume Guarantee With the Dräger Babylog VN500 Neonatal Ventilator

Objectives: To investigate how compensating for endotracheal tube leaks by targeting the leak-compensated tidal volume affects measured physiologic and ventilator variables during neonatal mechanical ventilation. Design: Retrospective observational study. Setting: A level III Neonatal ICU. Patients: We enrolled 30 neonates who were ventilated using synchronized intermittent positive pressure mode with volume guarantee and had at least 12 hours of continuous detailed recording of ventilation variables. Interventions: Infants were treated using the Dräger VN500 ventilator (Dräger, Lübeck, Germany), which uses a proprietary algorithm to measure and compensate for endotracheal tube leaks. Eleven were ventilated without leak compensation and 19 with leak compensation. Measurements and Main Results: Detailed ventilation data were collected and analyzed at 1 Hz, with intermittent blood gas values. The percentage of leak was less than 20% in 73% of leak-compensated inflations, and the volume of the leak compensation was less than 1 mL/kg in 97.3% of inflations. Between the two groups, ventilation variables were comparable, except the percentage of leak that was significantly (p = 0.005) higher in the recordings with leak compensation. Without leak compensation, the mean expired tidal volume was maintained very close to the set level up to 50% leak, but with leaks greater than 50%, it declined progressively. With leak compensation, the mean leak-compensated expired tidal volume was well maintained even with leak greater than 90% although with large variability. Without leak compensation, the difference between the maximum allowed inflating pressure and the peak inflating pressure decreased progressively as the leak increased. This did not occur with leak compensation. The median PCO2 was slightly higher with leak compensation. Conclusions: During volume guarantee ventilation with a Dräger VN500 ventilator, without leak compensation the expired tidal volume declined after 50% leak. With leak compensation, the tidal volume was maintained even with a large leak. With leak compensation, there was a more stable peak inflating pressure, although the PCO2 was slightly higher. This work was performed at the Neonatal ICU, The Rosie Hospital, Cambridge, United Kingdom. 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 (https://ift.tt/2gIrZ5Y). Dr. Morley received funding from Fisher and Paykel Healthcare, Acutronic Medical Instruments, and Chiesi Pharmaceuticals (honorarium for lectures), and he disclosed off-label product use of Drager Medical Neonatal Ventilator VN500. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: gusztav.belteki@addenbrookes.nhs.uk ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Tox and Hound – Fellow Friday – Methylene Blue Infusions

Continuous Methylene Blue Infusions for Treating Recurrent Methemoglobinemia by Steve Curry Banner – University Medical Center Phoenix University of Arizona College of Medicine – Phoenix A 2012 report out of Oregon serves as one of many examples reminding us that some serious cases of methemoglobinemia require more than a single injection of methylene blue in […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Fellow Friday

Welcome to Fellow Friday! As a new feature, your friends at The Tox & The Hound will have regularly occurring posts from exciting guest authors that take a deep, deep dive into deeper toxicology topics. Posts that will have toxicology fellows putting down their slide rule, straightening their pocket protectors, and taking notes. Love structures? […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Fellow Friday – Methylene Blue Infusions

Continuous Methylene Blue Infusions for Treating Recurrent Methemoglobinemia by Steve Curry Banner – University Medical Center Phoenix University of Arizona College of Medicine – Phoenix A 2012 report out of Oregon serves as one of many examples reminding us that some serious cases of methemoglobinemia require more than a single injection of methylene blue in […]

EMCrit Project by Tox & Hound.

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Tox and Hound – Fellow Friday

Welcome to Fellow Friday! As a new feature, your friends at The Tox & The Hound will have regularly occurring posts from exciting guest authors that take a deep, deep dive into deeper toxicology topics. Posts that will have toxicology fellows putting down their slide rule, straightening their pocket protectors, and taking notes. Love structures? […]

EMCrit Project by Tox & Hound.

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Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center

Resuscitation

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Admission Hyperoxia Is a Risk Factor for Mortality in Pediatric Intensive Care

Objectives: To determine whether the association between hyperoxia and increased risk-adjusted mortality in adult intensive care patients is also observed in a pediatric intensive care population. Design: Single-center retrospective analysis of admissions to ICU over a 5-year period commencing January 1, 2012, examining the relationship between PaO2 measured within the first hour of admission and risk-adjusted mortality. Standardized mortality rates were calculated using the Pediatric Index of Mortality-3, and patients were grouped into 50 mm Hg (6.67 kPa) PaO2 bands to assess the relationship between initial PaO2 and risk-adjusted mortality. Setting: Tertiary PICU with 17 beds and 1,100 annual admissions located in metropolitan Sydney, Australia. Patients: A total of 1,447 patients 0–18 years old with PaO2 recorded at admission to the ICU. Interventions: None. Measurements and Main Results: There were 5,176 patients admitted to the ICU during the study period and 1,447 (28%) with PaO2 recorded at admission. A U-shaped relationship between raw mortality and admission PaO2 was observed, with lowest mortality (2.3% and 2.6%, respectively) observed in the 101–150 (13.5–20.0 kPa) and 151–200 mm Hg (20.1–26.7 kPa) bands and the highest mortality observed in patients with PaO2 less than 50 mm Hg (6.67 kPa) with mortality of 5.3%, or greater than 350 mm Hg (46.7 kPa) with mortality of 18.2%. Hyperoxia at admission was associated with an increase in risk-adjusted mortality, with polynomial regression indicating a strong correlation between PaO2 band and risk-adjusted outcome (r2 = 0.845). When included in a multivariate model that included the Pediatric Index of Mortality-3 variables, the odds ratio for hyperoxia (defined as PaO2 > 250 mm Hg [33.3 kPa]) predicting death was 2.66 (p = 0.047). Conclusions: In this single-center study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. Further investigation of these observations in a large multicenter cohort is warranted. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: a.numa@unsw.edu.au ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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No Requirement for Targeted Theophylline Levels for Diuretic Effect of Aminophylline in Critically Ill Children

Objectives: To determine the relationship between theophylline trough levels and urine output in critically ill children administered aminophylline as adjunctive diuretic therapy. Design: Retrospective cohort study. Setting: The PICU of a tertiary care children’s hospital. Patients: A mixed population of medical/surgical including postoperative cardiothoracic surgery patients less than 18 years old. Interventions: Electronic medical records of all PICU patients admitted from July 2010 to June 2015 were reviewed, and patients who received aminophylline as diuretic therapy were identified. Measurements and Main Results: Patient cohort data including demographics, daily aminophylline, furosemide and chlorothiazide dosing, theophylline trough levels, fluid intake, urine output and total fluid balance, blood urea nitrogen, and creatinine levels were abstracted. Multivariate analysis based on a generalized estimating equations approach demonstrated that aminophylline administration, when analyzed as a categorical variable, was associated with an increase in urine output and decreased fluid balance. However, aminophylline dosing, when analyzed as a continuous variable, was associated with neither an increase in urine output nor decreased fluid balance. Theophylline trough levels were not correlated with urine output at 24 hours (p = 0.78) and were negatively correlated with urine output at 48 hours (r2 = 0.078; p

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Fosphenytoin Population Pharmacokinetics in the Acutely Ill Pediatric Population

Objective: The purpose of this study is to describe the pharmacokinetics of phenytoin in pediatric patients receiving fosphenytoin. Design: Retrospective, population pharmacokinetic analysis. Setting: Emergency department or PICU of a large tertiary care children’s hospital. Patients: Patients less than 19 years old who received fosphenytoin in the PICU or emergency center for treatment of seizures from January 2011 to June 2017 were included. Interventions: Population pharmacokinetic analysis was performed with NONMEM v7.3 (Icon Plc, Dublin, Ireland). Simulation was performed to determine optimal loading dose and maintenance dosing regimens. Measurements and Main Results: A total of 536 patients (55.4% male; median age, 3.4 yr [interquartile range, 0.92–8.5 yr]) met study criteria. Fosphenytoin was administered at median 15.1 mg/kg/dose (interquartile range, 6.3–20.7 mg/kg/dose). Mean serum concentrations of 17.5 ± 7.8 mg/L were at a median 4.2 hours (interquartile range, 2.5–7.8 hr) after a dose. A pharmacokinetic model with two compartments, allometrically scaled fat-free mass on all parameters, and serum creatinine and concomitant phenobarbital use on clearance had the best fit. Simulation demonstrated that a 20 mg/kg loading dose followed by 6 mg/kg/dose every 8 hours had the greatest percentage of concentrations in the 10–20 mg/L range, with reduced doses to achieve therapeutic in patients with reduced kidney function. Conclusions: A loading dose of 20 mg/kg followed by 6 mg/kg/dose every 8 hours based on fat-free mass is a reasonable empiric strategy for attainment and maintenance of therapeutic trough concentrations. Concomitant phenobarbital use may increase clearance of phenytoin and fosphenytoin dose reductions should occur in patients with reduced kidney function. 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 (https://ift.tt/2gIrZ5Y). Dr. Weingarten received funding from Greenwich Pharmaceuticals. Drs. Weingarten and Riviello disclosed off-label product use in the article. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: bsmoffet@texaschildrens.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Platelet Transfusions in the PICU: Does Disease Severity Matter?

Objectives: Pediatric intensivists frequently prescribe platelet transfusions to critically ill children, but there are limited data on platelet transfusion practice and platelet transfusion–related outcomes in the PICU. In this study, we evaluated the current platelet transfusion practice and platelet transfusion–related outcomes in the PICU. Design: Institutional review board–approved, retrospective cohort study from January 2010 to March 2016. Setting: Tertiary-level PICU. Patients: Children less than 19 years old who received platelet transfusions in the PICU. Interventions: None. Measurements and Main Results: Thirty-six percent (1,547/4,339) of platelet transfusions in the institution were given to 2.4% of PICU patients (232/9,659). The patients who received a platelet transfusion (platelet transfusions, n = 232) compared with those who did not receive platelets (no platelet transfusions, n = 9,427) were younger, had similar gender distribution, had a higher median Pediatric Risk of Mortality-3 score, and stayed longer in the PICU. Fifty percent of platelet transfusions were prescribed prophylactically for thrombocytopenia to patients without extracorporeal membrane oxygenation support. The mortality was higher for platelet transfusions group (30% vs 2.3%) with an 18 times increased unadjusted odds of mortality when compared with no platelet transfusion group (odds ratio, 18.2; 95% CI, 13.3–24.8; p

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Long-term risk of seizures among cardiac arrest survivors

Resuscitation

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Significantly different clinical features between hypertriglyceridemia and biliary acute pancreatitis: A retrospective study of 730 patients from a tertiary center

BMC Gastroenterology

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Estimating mean circulatory filling pressure in clinical practice: a systematic review comparing three bedside methods in the critically ill

The bedside hemodynamic assessment of the critically ill remains challenging since blood volume, arterial–venous interaction and compliance are not measured directly. Mean circulatory filling pressure (Pmcf) is t...

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High flow nasal cannula oxygen versus noninvasive ventilation in adult acute respiratory failure: a systematic review of randomized-controlled trials

We reviewed the use of noninvasive ventilation (NIV) versus high flow nasal cannula (HFNC) oxygen in adult acute respiratory failure (ARF). We searched major databases and included randomized trials comparing at least NIV with HFNC or NIV+HFNC with NIV in ARF. Primary outcomes included intubation/re-intubation rates. Secondary outcomes were ICU mortality and morbidities. Five trials were included; three compared HFNC with NIV, one compared HFNC, NIV and oxygen whereas one compared HFNC+NIV with NIV. Patients had hypoxaemic ARF (PaO2/FiO2≤300 mmHg). Heterogeneity prevented result pooling. Three and two studies had superiority and noninferiority design, respectively. Patients were postcardiothoracic surgery, mixed medical/surgical patients and those with pneumonia. Two trials were conducted after extubation, two before intubation and one during intubation. Three trials reported intubation/re-intubation rates as the primary outcomes. The other two trials reported the lowest peripheral capillary oxygen saturation readings during bronchoscopy or intubation. In the former three trials, the odds ratio for intubation/re-intubation rates between HFNC versus the NIV group ranged from 0.80 (95% confidence interval: 0.54–1.19) to 1.65 (95% confidence interval: 0.96–2.84). In the latter two trials, only one reported a difference in the lowest peripheral capillary oxygen saturation between NIV+HFNC versus the NIV group during intubation [100% (interquartile range: 95–100) vs. 96% (interquartile range: 92–99); P=0.029]. The secondary outcomes included differences in ICU mortality and patient tolerability, favouring HFNC, were conflicting, but highlighted future research directions. These include patients with hypercapneic ARF, more severe hypoxaemia (PaO2/FiO2≤200 mmHg), a superiority design, an oxygen arm and patient-centred outcomes. Correspondence to Lim Beng Leong, MBBS, MRCS, FAMS, MCI, Ng Teng Fong Emergency Department, National University Healthcare Cluster, 1, Jurong East Street 21, Singapore 609606, Singapore Tel: +65 6716 5340; fax: +65 6397 3568; e-mail: beng_leong_lim@nuhs.edu.sg Received September 6, 2017 Accepted May 1, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Hypertonic Lactate to Improve Cerebral Perfusion and Glucose Availability After Acute Brain Injury

Objectives: Lactate promotes cerebral blood flow and is an efficient substrate for the brain, particularly at times of glucose shortage. Hypertonic lactate is neuroprotective after experimental brain injury; however, human data are limited. Design: Prospective study (clinicaltrials.gov NCT01573507). Setting: Academic ICU. Patients: Twenty-three brain-injured subjects (13 traumatic brain injury/10 subarachnoid hemorrhage; median age, 59 yr [41–65 yr]; median Glasgow Coma Scale, 6 [3–7]). Interventions: Three-hour IV infusion of hypertonic lactate (sodium lactate, 1,000 mmol/L; concentration, 30 µmol/kg/min) administered 39 hours (26–49 hr) from injury. Measurements and Main Results: We examined the effect of hypertonic lactate on cerebral perfusion (using transcranial Doppler) and brain energy metabolism (using cerebral microdialysis). The majority of subjects (13/23 = 57%) had reduced brain glucose availability (baseline pretreatment cerebral microdialysis glucose, 0.1). Conclusions: This is the first clinical demonstration that hypertonic lactate resuscitation improves both cerebral perfusion and brain glucose availability after brain injury. These cerebral vascular and metabolic effects appeared related to brain lactate supplementation rather than to systemic effects. Drs. Carteron and Solari are co-first authors and contributed equally to this work. Supported, in part, by grants from the Swiss National Science Foundation (320030_138191 and 32003B_155957 [to Dr. Oddo]), the Novartis Foundation for Biomedical Research (to Dr. Oddo), and the Société Française d’Anesthésie et de Réanimation and the Fondation des Gueules Cassées (both to Dr. Carteron). Dr. Hirt received other support from Boehringer Ingelheim (speaker fees and travel grants, not related to this work) and research grants not in relation with this work from the Swiss Science Foundation, the Biaggi Foundation, and the Juchum Foundation. Dr. Oddo received support for article research from the Swiss National Science Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: mauro.oddo@chuv.ch Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Etomidate Is “Not” a First-Line Induction Agent in Critically Ill Patients: Primum Non Nocere—Above All, Do No Harm

No abstract available

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Etomidate Is a First-Line Induction Agent in Critically Ill Patients

No abstract available

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Adenosine Plasma Level and A2A Receptor Expression in Patients With Cardiogenic Shock

Objectives: To investigate whether adenosine A2A receptors lead to vasodilation and positive inotropic function under stimulation and whether they play a role in the control of blood pressure in patients with cardiogenic shock. Design: Prospective observational study. Setting: Monocentric, Hopital Nord, Marseille, France. Subjects: Patients with cardiogenic shock (n = 16), acute heart failure (n = 16), and acute myocardial infarction (n = 16). Interventions: None. Measurements and Main Results: Arterial adenosine plasma level and A2A receptor expression on peripheral blood mononuclear cells were evaluated by mass spectrometry and Western blot, respectively, at admission and after 24 hours. Hemodynamic parameters, including systemic vascular resistance, were also assessed. Mean adenosine plasma level at admission was significantly higher in patients with cardiogenic shock (2.74 ± 1.03 µM) versus acute heart failure (1.33 ± 0.27) or acute myocardial infarction (1.19 ± 0.27) (normal range, 0.4–0.8 µM) (p

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Prophylactic Seizure Medication and Health-Related Quality of Life After Intracerebral Hemorrhage

Objectives: Prophylactic levetiracetam is currently used in ~40% of patients with intracerebral hemorrhage, and the potential impact of levetircetam on health-related quality of life is unknown. We tested the hypothesis that prophylactic levetiracetam is independently associated with differences in cognitive function health-related quality of life. Design: Patients with intracerebral hemorrhage were enrolled in a prospective cohort study. We performed mixed models for T-scores of health-related quality of life, referenced to the U.S. population at 50 ± 10, accounting for severity of injury and time to follow-up. Setting: Academic medical center. Patients: One-hundred forty-two survivors of intracerebral hemorrhage. Interventions: None. Measurements and Main Results: T-scores of Neuro-Quality of Life Cognitive Function v2.0 was the primary outcome, whereas Neuro-Quality of Life Mobility v1.0 and modified Rankin Scale (a global functional scale) were secondary measures. We prospectively documented if prophylactic levetiracetam was administered and retrieved administration data from the electronic health record. Patients who received prophylactic levetiracetam had worse cognitive function health-related quality of life (T-score 5.1 points lower; p = 0.01) after adjustment for age (p = 0.3), National Institutes of Health Stroke Scale (p 0.1). Conclusions: Prophylactic levetiracetam was independently associated with lower cognitive function health-related quality of life at follow-up after intracerebral hemorrhage. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Agency for Healthcare Research and Quality. Dr. Naidech designed and conceptualized the study, analyzed and interpreted the data, collected study data, drafted the article, and revised the article for important intellectual content. Dr. Naidech performed the statistical analysis under guidance from the National Institutes of Health Patient-Reported Outcomes Measurement Information System Statistical Center (to Dr. Cella, Ms. Beaumont). Ms. Beaumont oversaw the statistical analysis. Dr. Muldoon collected study data and revised the article for important intellectual content. Drs. Liotta, Potts, Jahromi, Cella, Prabhakaran, and Holl revised the article for important intellectual content. Dr. Maas designed and conceptualized the study and collected study data. Supported, in part, by the National Institutes of Health’s National Center for Advancing Translational Sciences grant UL1 TR000150. Dr. Naidech’s institution received funding from the Agency for Healthcare Research and Quality (AHRQ), and he received support for article research from the AHRQ (K18 HS023437) and the National Institutes of Health (NIH). Dr. Liotta’s institution received funding from NIH National Center for Advancing Translational Sciences grant KL2TR001424, and he received funding from the NIH Division of Loan Repayment grant L30NS098427. Dr. Maas’ institution received funding from the NIH grants K23 NS092975 and L30 NS080176 and a Dixon Translational Research Grant from the Northwestern Memorial Foundation, and he received support for article research from the NIH. Dr. Cella’s institution received funding from the National Institutes of Neurological Disorders and Stroke U01 NS 056 975 02 and NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases, U5 AR057951, and he received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: a-naidech@northwestern.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Mortality and associated risk factors for older adults admitted to the Emergency Department: A hospital cohort

BMC Geriatrics

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Multiple Micronutrient Plasma Level Changes Are Related to Oxidative Stress Intensity in Critically Ill Children

Objectives: Micronutrient supplementation in critically ill adults remains controversial. In the pediatric setting, the impact of oxidative stress on the overall micronutrient status has been poorly explored, due to the limited number of studies and to confounding factors (i.e., malnutrition or extra losses). In order to better understand this phenomenon, we aim to describe micronutrient status, focusing on seven micronutrients, in well-nourished critically ill children presenting with severe oxidative stress. Design: Prospective, transversal, observational, single-center study. Setting: PICU, and anesthesiology department, Lyon, France. Patients: Three groups of patients were clinically defined: severe oxidative stress PICU group (at least two organ dysfunctions), moderate oxidative stress PICU group (single organ dysfunction), and healthy control group (prior to elective surgery); oxidative stress intensity was controlled by measuring plasma levels of glutathione peroxidase and glutathione. Children presenting any former condition leading to micronutrient deficiency were excluded (malnutrition, external losses). Interventions: Plasma levels of selenium, zinc, copper, vitamin A, vitamin E, vitamin C, and β-carotene were measured in PICU oxidative stress conditions and compared with those of healthy children. Measurements and Main Results: Two hundred one patients were enrolled (51, 48, and 102 in severe, moderate, and healthy control groups, respectively). Median age was 7.1 years (interquartile range, 2.1–13.8 yr). There was a significant trend (p

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Pulmonary Functions in Children Ventilated for Acute Hypoxemic Respiratory Failure

Objective: To assess pulmonary functions of children who received mechanical ventilation for acute hypoxemic respiratory failure. Design: Longitudinal study. Setting: PICU and Pediatric Pulmonology Clinic of a tertiary care teaching hospital in North India. Patients: All children, 5–12 years old, ventilated for acute hypoxemic respiratory failure in PICU from July 2012 to June 2013 and survived. Interventions: The baseline admission variables recorded were as follows: age, sex, duration of illness, primary diagnosis at admission, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices, and duration of PICU stay. The children were followed up twice, at 3 and 9–12 months, after discharge from PICU and evaluated for any residual respiratory symptoms and signs, pulse oximetry, chest radiograph, 6-minute walk test, peak expiratory flow rate, and spirometry. Age, sex, duration of illness, primary diagnosis, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices (PaO2/FIO2 ratio and oxygenation index), and duration of PICU stay were recorded from patient records. Measurements and Main Results: Twenty-nine children (25 boys and four girls; mean [SD] age, 8.4 [2.4] yr) were followed up at 3.5 (± 1.2) and 10.6 (± 2.7) months after discharge from PICU. Recurrent respiratory symptoms were noted in 37.9% patients (11/29) during first and in none during second follow-up. None had limitation of physical activity or need of supplemental oxygen. Chest examination was normal in all, except one during first follow-up, but 13.8% (4/29) had abnormal chest radiograph during first follow-up. Nearly all children could perform 6-minute walk test although mean distance walked increased significantly from first (352 ± 66.7 m) to second follow-up (401 ± 60.7 m; p = 0.002). Abnormal spirometry was seen in 82.7% (24/29) versus 18.5% (5/27) children during first and second follow-up visits, respectively (p = 0.0001). Most cases had restrictive abnormality (58.6% vs 11.1%; p = 0.002) during first and second follow-up, respectively. There was no correlation between pulmonary functions and lung injury scores, oxygenation indices (PaO2/FIO2 ratio and oxygenation index), and mechanical ventilation parameters. Conclusions: Significant number of children ventilated for acute hypoxemic respiratory failure had subclinical pulmonary function abnormality, without limiting physical activity, which improved over time. Further research on this topic with a larger sample size and patient categorization according to recent pediatric acute respiratory distress syndrome definition is needed. Drs. Chakdour and Vaidya contributed equally to this work. Dr. Singhi received grants from World Health Organization and the Indian Council of Medical Research. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: sunit.singhi@gmail.com ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Comparison of Pediatric Cardiopulmonary Resuscitation Quality in Classic Cardiopulmonary Resuscitation and Extracorporeal Cardiopulmonary Resuscitation Events Using Video Review

Objectives: To assess differences in cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation events using video recordings of actual pediatric cardiac arrest events. Design: Single-center, prospective, observational trial. Setting: Tertiary-care pediatric teaching hospital, cardiac ICU. Patients: All patients admitted to the pediatric cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. Interventions: None. Measurements and Main Results: Seventeen events comprising 264.5 minutes of cardiopulmonary resuscitation were included: 11 classic cardiopulmonary resuscitation events (87.5 min) and six extracorporeal cardiopulmonary resuscitation events (177 min). Events were divided into 30-second epochs, and cardiopulmonary resuscitation quality markers were assessed using video and telemetry data review of goal endpoints: end-tidal carbon dioxide greater than or equal to 15 mm Hg, diastolic blood pressure greater than or equal to 30 mm Hg, chest compression fraction greater than 80% per epoch, and chest compression rate between 100 and 120 chest compression per minute. Additionally, each chest compression pause (hands-off event) was recorded and timed. When compared with extracorporeal cardiopulmonary resuscitation, classic cardiopulmonary resuscitation epochs were more likely to have end-tidal carbon dioxide greater than or equal to 15 mm Hg (56% vs 6.2%; p = 0.01) and provide chest compression between 100 and 120 times per minute (112 vs 134 chest compression per minute; p

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Predictive Factors for Central Line–Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax

Objectives: To assess the prevalence of central line–associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line–associated bloodstream infection. Design: Retrospective single-center cohort study. Setting: A PICU located within a tertiary-care academic pediatric hospital. Patients: All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014. Interventions: None. Measurements and Main Results: We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line–associated bloodstream infection (23% vs 3.8%; p

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PICU Provider Supply and Demand: A National Survey

Objectives: To describe physicians’ and nurse practitioners’ perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs. Design: National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017. Setting: Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners. Subjects: PICU physician medical directors and nurse practitioners. Interventions: None. Measurements and Main Results: There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner’s role in patient care. Conclusions: Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery. This work was performed at Vanderbilt University, Nashville, TN. Supported, in part, by the Vanderbilt University School of Nursing PhD Student Research Award, the Iota Chapter of Sigma Theta Tau International, and Clinical Translational Science Award Research Electronic Data Capture. Dr. Gigli received funding from Vanderbilt University School of Nursing PhD Research Award and Iota Chapter of Sigma Theta Tau International. Dr. Buerhaus disclosed receiving limited payment from Vanderbilt University for serving on Dr. Gigli’s dissertation committee. Dr. Minnick partially supported mailing through her endowed chair. Dr. Dietrich has disclosed that she does not have any potential conflicts of interest. Address requests for reprints to: Kristin H. Gigli, PhD, RN, CPNP-AC, CCRN, Vanderbilt University School of Nursing, 461 21st Ave South, Nashville, TN 37240. E-mail: hittlek@gmail.com ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Factors Associated With Mechanical Ventilation Use in Children With Sickle Cell Disease and Acute Chest Syndrome

Objectives: Acute chest syndrome is the leading cause of death in children with sickle cell disease and is generally due to respiratory failure. Epidemiologic factors for a need for mechanical ventilation in children with acute chest syndrome require further clarification. Design: Retrospective observational study. Setting: Nationally representative pediatric inpatient records in the United States by using the Kids’ Inpatient Database for the years 2003, 2006, 2009, and 2012. Patients: Patients age less than 20 years old with a discharge diagnosis of acute chest syndrome. Measurements and Marin Results: Data were weighted to estimate annual hospitalizations according to hospital characteristics in the United States. Multivariable logistic regression was conducted to ascertain factors associated with use of mechanical ventilation, after adjusting for patient and hospital characteristics. Total hospitalizations for acute chest syndrome were 5,018 in 2003, 6,058 in 2006, 6,072 in 2009, and 6,360 in 2012. Mechanical ventilation use was associated with comorbidities of obesity (odds ratio, 3.35; 95% CI, 1.94–5.78), obstructive sleep apnea (odds ratio, 3.72; 95% CI, 2.23–6.20), and heart disease (odds ratio, 2.19; 95% CI, 1.47–3.27). In addition, nonblack compared with black children (odds ratio, 1.53; 95% CI, 1.02–2.31) and the fall season (p = 0.018) were associated with mechanical ventilation use. Conclusions: Comorbidity of obesity, obstructive sleep apnea, or heart disease could be potentially associated with mechanical ventilation use during an episode of acute chest syndrome. Prospective observational studies would be required to confirm these findings and infer potential interventions for preventing illness severity. 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 (https://ift.tt/2gIrZ5Y). Dr. Okubo was supported by grants from the Ministry of Health, Labor and Welfare, Japan. Dr. Miller’s institution received funding from the National Institutes of Health/Heart, Lung, and Blood Institute (investigator), Pfizer/Paraxel (investigator, clinical trial), and Emmaus Pharmaceutical (investigator, clinical trial). The other authors have no research or project support, including internal funding. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: sunning_dale@yahoo.co.jp ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Intensive Care Mortality Prognostic Model for Pediatric Pulmonary Hypertension

Objectives: The disease burden and mortality of children with pulmonary hypertension are significantly higher than for the general PICU population. We aimed to develop a risk-adjustment tool predicting PICU mortality for pediatric pulmonary hypertension patients: the Pediatric Index of Pulmonary Hypertension Intensive Care Mortality score. Design: Retrospective analysis of prospectively collected multicenter pediatric critical care data. Setting: One-hundred forty-three centers submitting data to Virtual Pediatric Systems database between January 1, 2009, and December 31, 2015. Patients: Patients 21 years old or younger with a diagnosis of pulmonary hypertension. Interventions: Twenty-one demographic, diagnostic, and physiologic variables obtained within 12 hours of PICU admission were assessed for inclusion. Multivariable logistic regression with stepwise selection was performed to develop the final model. Receiver operating characteristic curves were used to compare the Pediatric Index of Pulmonary Hypertension Intensive Care Mortality score with Pediatric Risk of Mortality 3 and Pediatric Index of Mortality 2 scores. Measurements and Main Results: Fourteen-thousand two-hundred sixty-eight admissions with a diagnosis of pulmonary hypertension were included. Primary outcome was PICU mortality. Fourteen variables were selected for the final model: age, bradycardia, systolic hypotension, tachypnea, pH, FIO2, hemoglobin, blood urea nitrogen, creatinine, mechanical ventilation, nonelective admission, previous PICU admission, PICU admission due to nonsurgical cardiovascular disease, and cardiac arrest immediately prior to admission. The receiver operating characteristic curve for the Pediatric Index of Pulmonary Hypertension Intensive Care Mortality model (area under the curve = 0.77) performed significantly better than the receiver operating characteristic curves for Pediatric Risk of Mortality 3 (area under the curve = 0.71; p

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Safety and Efficacy of IV Lidocaine in the Treatment of Children and Adolescents With Status Migraine

Objectives: To evaluate the safety and efficacy of IV lidocaine in treating children and adolescents with status migraine. Design: Retrospective observational study. Setting: Single center PICU. Patients: Children and adolescents admitted with status migraine. Intervention: IV lidocaine. Measurement and Main Results: Thirty-three lidocaine infusions were administered to 28 patients with status migraine. Two patients were excluded from analysis, leaving 31 infusions administered to 26 patients for analysis. Patients’ ages ranged from 10 to 19 years with an average of 14.9 ± 2.4 years. Mean duration of hospitalization was 4.6 ± 1.5 days. Lidocaine was administered as a bolus (2.9 ± 0.18 mg/kg) in 80.6% (95% CI, 63.7–90.8%) of the patients, followed by an infusion, which was started at a mean rate of 1.29 ± 0.2 mg/kg/hr with mean maximum dose of 1.56 ± 0.27 mg/kg/hr. The highest lidocaine drip was 2.25 mg/kg/hr and lowest 1.125 mg/kg/hr. Lidocaine was interrupted in one patient secondary to side effects: chest pain and anxiety. On average, it took 16.3 ± 12.9 hours for 50% reduction in pain scores (range, 1.3–40.4 hr) and 19.3 ± 19.3 hours for complete resolution (0.8–72.1). 90.3% of cases (95% CI, 75.1–96.6%) experienced pain resolution with 51.6% (95% CI, 34.8–68%) encountering a relapse of pain. Mean pain scores at the time of discharge were 1 ± 1.6 (median, 0). Both mean reported highest and lowest scores dropped over the course of the 5 days from 5.1 ± 1.9 and 2.1 ± 2.4 on day 1 to 1.0 ± 1.4 and 0 on day 5 of therapy. One-way analysis by analysis of variance for high pain score by day was statistically significant with a p value of less than 0.01. Conclusions: In the appropriate patient population, IV lidocaine may be a safe and effective treatment for children and adolescents with status migraine. Larger prospective studies need to be done not only to evaluate safety and efficacy but also the analgesic longevity of IV lidocaine post discharge. The findings and conclusions in this article are those of the authors. All investigations were performed at Fountain Valley Regional Hospital and Medical Center. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: marcoayulo@gmail.com ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Predictive factors of intracranial bleeding in head trauma patients receiving antiplatelet therapy admitted to an emergency department

In head trauma cases involving antiplatelet agent treatment, the French Society of Emergency Medicine recommends performing computed tomography (CT) scans to detect brain lesions, 90% of which are normal. The ...

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Vascular complications in adult postcardiotomy cardiogenic shock patients receiving venoarterial extracorporeal membrane oxygenation

The rate, prognostic impacts, and predisposing factors of major vascular complications (MVCs) in patients underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) by surgical cut-down are poorly un...

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EMCrit – I Have Issues with Andexanet by K. Kipp, PharmD

I have a problem with Andexanet

EMCrit Project by Kristina Kipp.

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EMCrit – I Have Issues with Andexanet by K. Kipp, PharmD

I have a problem with Andexanet

EMCrit Project by Kristina Kipp.

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A clinical decision instrument to predict 30-day death & cardiovascular hospitalizations following an Emergency Department visit for atrial fibrillation: The atrial fibrillation in the emergency room, part 2 (AFTER2) study

American Heart Journal

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Life Lost Yet Lingering

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): Elizabeth C. Stachtiaris




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Issue Highlights

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1





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Hypothermia Outcome Prediction After Extracorporeal Lift Support for Hypothermic Cardiac Arrest Patients: The HOPE Score

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): Heather Roesly




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Contents

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1





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(LEFT) Partial Contents; (RIGHT) Elsevier E-alert 1/2 pg vertical BW filler

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1





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Prehospital End-Tidal Carbon Dioxide Predicts Mortality in Trauma Patients

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): Jamal Taha




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Assessment of the Utility of Ordering a Troponin in Low- and Intermediate-Risk Patients Presenting to the Emergency Department with Supraventricular Tachycardia: A Retrospective Chart Review

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): David Noorvash, Rosemarie Ramos, Linda Hatch, Andrew Muck, Adriana Segura Olson
BackgroundA troponin assay is commonly sent for patients presenting to emergency departments (EDs) with supraventricular tachycardia (SVT). Multiple studies suggest that elevated troponin levels do not predict coronary artery disease in these patients. Patients with elevated troponins are more likely to have additional cardiac testing, which can lead to increased health care costs and unnecessary invasive procedures.ObjectiveOur objective was to evaluate low- to intermediate-risk patients (HEART [history, electrocardiography, age, risk factors and troponin] Score 1–6) presenting to the ED with SVT. Our hypothesis was that an elevated troponin would not predict major adverse cardiac events (MACE), but would be associated with increased hospital admission rates and lengths of stay.MethodsThis was a retrospective cohort study of adult patients who presented with SVT to a large, urban, academic hospital ED over 4 years who had a troponin result. A total of 46 patients were included in the study.ResultsPatients with a positive troponin (>0.05 ng/mL) had a hospital admission rate of 86% versus 21% for patients with negative troponin (p = 0.006); rate of cardiology consult of 86% versus 21% (p < 0.001); and a mean total length of stay of 4157 min versus 1347 min (p = 0.04). At 3 months, none of the patients with a positive troponin had an MACE, death from any cause, or positive results of cardiac testing.ConclusionsPatients with a positive troponin result had significantly more admissions, cardiology consults, and longer hospital stays. These patients did not have an increased prevalence of MACE.



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Hydrocortisone plus Fludrocortisone for Adults with Septic Shock

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): Erin Lindsay




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A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers

Publication date: July 2018
Source:The Journal of Emergency Medicine, Volume 55, Issue 1
Author(s): Mark A. Snider, Jim Y. Wan, Jonathan Jacobs, Rudy Kink, Barry Gilmore, Sandra R. Arnold
BackgroundDespite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.ObjectiveWe compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.MethodsThis is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.ResultsWe enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8–11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of −0.9% (95% confidence interval −5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval −4% to 7%), which met the criteria for noninferiority.ConclusionsAlbuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.



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