H&H Medical Corporation launches Safe and Sound Schools fundraising initiative

H&H Medical Corporation, provider of high-quality products for emergency first responders, today kicked off its fundraising campaign to support Safe and Sound Schools. From July 1 through September 31, 2018, H&H Medical Corporation will donate a portion of revenue from online sales of select trauma kits and supplies to Safe and Sound Schools to help fund free programs and resources for...

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The Dantastic Mr. Tox & Howard – S02E02 – The Podcast That Mistook its Pediatrician for a Pork Roll

Small Poisoned Humans with Dr. Diane Calello Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Diane Calello and learn what a pediatrician, pediatric emergency physician, addiction specialist, medical toxicologist and lyric soprano does for fun. Learn what makes a kid a kid and what special things to look out for when managing future […]

EMCrit Project by Tox & Hound.

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The Dantastic Mr. Tox & Howard – S02E02 – The Podcast That Mistook its Pediatrician for a Pork Roll

Small Poisoned Humans with Dr. Diane Calello Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Diane Calello and learn what a pediatrician, pediatric emergency physician, addiction specialist, medical toxicologist and lyric soprano does for fun. Learn what makes a kid a kid and what special things to look out for when managing future […]

EMCrit Project by Tox & Hound.

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Paramedic honored for teaching more than 8K civilians CPR

Dave Kroll has volunteered numerous weekends over the past three years to teach hands-only CPR to the public

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Postextubation Dysphagia in Children: The Role of Speech-Language Pathologists

Objectives: Postextubation dysphagia is common and associated with worse outcomes in the PICU. Although there has been an increased participation of speech-language pathologists in its treatment, there is limited evidence to support speech-language pathologists as core PICU team member. We aimed to assess the impact of speech-language pathologists interventions on the treatment of postextubation dysphagia. Design: A quasi-experimental prospective study. In the historical group (controls), patients received a standard care management for dysphagia whereas the intervention group was routinely treated by speech-language pathologists. Setting: PICU of a tertiary hospital. Patients: Children who were endotracheally intubated for a period greater than 24 hours with greater oral intake limitation as defined by a Functional Oral Intake Scale less than or equal to 3. Intervention: Routine speech-language pathologist assessment. Measurements and Main Results: A total of 74 patients were enrolled to receive intervention (January 2015 to December 2016) and 41 patients to the historical group (January 2014 to December 2014). There were no differences in the demographic and clinical characteristics. The historical group had both longer time to initiate oral intake (7 vs 4 d; p = 0.0002; hazard ratio, 2.33) and to reach full oral intake compared with intervention group (9 vs 13 d; p

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Epidemiology of Disease and Mortality From a PICU in Mozambique

Objectives: Delivery of pediatric critical care in low-income countries is limited by a lack of infrastructure, resources, and providers. Few studies have analyzed the epidemiology of disease associated with a PICU in a low-income country. The aim of this study was to document the primary diagnoses and the associated mortality rates of patients presenting to a tertiary PICU in Mozambique in order to formulate quality improvement projects through an international academic partnership. We hypothesized that the PICU mortality rate would be high and that sepsis would be a common cause of death. Design: Retrospective, observational study. Setting: Tertiary academic PICU. Patients: All admitted PICU patients. Interventions: All available data collection forms containing demographic and clinical data of patients admitted to the PICU at Hospital Central de Maputo, Mozambique from January 2013 to December 2013 were analyzed retrospectively. Measurements and Main Results: The patient median age was 2 years (57% male). The most common primary diagnoses were malaria (22%), sepsis (18%), respiratory tract infections (12%), and trauma (6%). The mortality rate was 25%. Mortality rates were highest among patients with sepsis (59%), encephalopathy (56%), noninfectious CNS pathologies (33%), neoplastic diseases (33%), meningitis/encephalitis (29%), burns (26%), and cardiovascular pathologies (26%). The median length of PICU stay was 2 days. HIV exposure/infection had a nonstatistically significant association with mortality. Patients admitted for burns had the highest median length of PICU stay (4 d). Most trauma admissions were male (75%), and approximately half of all trauma admissions had an associated head injury (55%). Conclusions: Infectious disease and trauma were highly represented in this Mozambican PICU, and overall mortality was high compared with high-income countries. With this knowledge, targeted collaborative projects in Mozambique can now be created and modified. Further research is needed to monitor the potential benefits of such interventions. This work was performed at Hospital Central de Maputo, Universidade Eduardo Mondlane, Maputo, Mozambique. The findings and conclusions presented are those of the authors and do not necessarily represent the official position of the funding agencies. This partnership has been supported, in part, by the President’s Emergency Plan for AIDS Relief through the Health Resources and Services Administration under the terms of Cooperative Agreement U97HA04128. This partnership, as well as this research study, has been supported by Anadarko Petroleum, the UCLA Center for World Health, Mending Kids International, Sun West Mortgage, the UCLA AIDS Institute, the NIH/NCRR/NCATS UCLA CTSI Grant UL1TR000124, and the Department of Surgery at the David Geffen School of Medicine at UCLA. Drs. Hall, Seni, DeUgarte, and Kelly received support for article research from the National Institutes of Health. Drs. Hall’s, Seni’s, Buck’s, and Kelly’s institutions received funding from President’s Emergency Plan for AIDS Relief through the Health Resources and Services Administration under the terms of Cooperative Agreement U97HA04128, Mending Kids International, Sun West Mortgage, and Anadarko Petroleum. Dr. Hartford disclosed that she was employed by the University of California Los Angeles as a pediatrician and partnership director for the partnership between UCLA and Maputo Central Hospital during the study data collection time frame. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Robert B. Kelly, MD, Children’s Hospital of Orange County, 1201 West La Veta Avenue, Orange, CA 92868. E-mail: rkelly@choc.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Population Pharmacokinetics of Vancomycin in Pediatric Extracorporeal Membrane Oxygenation

Objectives: Describe the pharmacokinetics of vancomycin in pediatric patients undergoing extracorporeal membrane oxygenation and provide dosing recommendations to attain an area under the curve for 24 hours greater than 400 in this population. Design: Retrospective, population pharmacokinetic analysis. Setting: PICU of a large tertiary care children’s hospital. Interventions: Population pharmacokinetic analysis and simulation were performed with NONMEM v7.3 (Icon, PLC, Dublin, Ireland). Patients: Patients less than 19 years old who received IV vancomycin and had serum vancomycin concentration monitoring while undergoing extracorporeal membrane oxygenation from January 1, 2011, to June 30, 2017. Measurements and Main Results: A total of 93 patients met study criteria (male 51%, median age 0.64 yr [interquartile range 0.07–6.7 yr]). Mean estimated creatinine clearance was 65 ± 47 mL/min/1.73 m2. Patients received 1,116 vancomycin doses (14.6 ± 1.9 mg/kg/dose) and had 433 vancomycin serum concentrations (13.6 ± 6.9 mg/L) at 13.2 ± 10.7 hours after a dose. A two-compartment pharmacokinetic model with allometrically scaled weight on clearance (0.75) and volumes of distribution (1) was developed. Serum creatinine, postmenstrual age were significant covariates for clearance, patient age for central volume of distribution, and albumin for peripheral volume of distribution. Simulation identified a doses of 25–30 mg/kg/dose every 12–24 hours as having the highest percentage of patients with an area under the curve for 24 hours greater than 400 with the highest percentage trough concentrations in the less than 15 mg/L range. Conclusions: A vancomycin dose of 25–30 mg/kg/dose every 12–24 hours with serum concentration monitoring is a reasonable empiric dosing strategy to obtain an area under the curve for 24 hours greater than 400 in pediatric extracorporeal membrane oxygenation patients. 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. Moffett disclosed off-label product use of vancomycin in Pediatric extracorporeal membrane oxygenation patients. Dr. Morris received funding from American College of Clinical Pharmacy (travel reimbursement for board preparatory course faculty). Dr. Munoz received support for article research from the National Institutes of Health. Dr. Arikan received funding from Baxter. Ms. Galati disclosed that she does 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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Iodide Improves Outcome After Acute Myocardial Infarction in Rats and Pigs

Objectives: In this study, we tested whether iodide would reduce heart damage in rat and pig models of acute myocardial infarction as a risk analysis for a human trial. Design: Prospective blinded and randomized laboratory animal investigation. Setting: Animal research laboratories. Subjects: Sexually mature rats and pigs. Interventions: Acute myocardial infarction was induced by temporary ligation of the coronary artery followed by reperfusion. Iodide was administered orally in rats or IV in rats and pigs just prior to reperfusion. Measurements and Main Results: Damage was assessed by blood cardiac troponin and infarct size; heart function was determined by echocardiography. Blood peroxide scavenging activity was measured enzymatically, and blood thyroid hormone was determined using radioimmune assay. Iodide administration preserved heart function and reduced blood cardiac troponin and infarct size by approximately 45% in pigs and approximately 60% in rats. Iodide administration also increased blood peroxide scavenging activity and maintained thyroid hormone levels. Conclusions: Iodide administration improved the structure and function of the heart after acute myocardial infarction in rats and pigs. Supported both by an Army Research Office grant to Dr. Roth for pig experiments performed at Fred Hutchinson Cancer Research Center and Puget Sound Veterans Administration and by Faraday Pharmaceuticals for rat experiments performed at Faraday Pharmaceuticals. Drs. Morrison’s and Iwata’s, Mr. Keyes’, and Dr. Roth’s institution received funding from Army Research Offices and Faraday Pharmaceuticals. Drs. Morrison, Iwata and Roth are named inventors on patents licensed to Faraday Pharmaceuticals; they received funding from Faraday Pharmaceuticals (royalties and shares). Dr. Langston and Mr. Insko are employees of Faraday Pharmaceuticals. Dr. Langdale’s institution received funding from the Department of Defense (DoD); she received support for article research from the DoD; and she disclosed government work. For information regarding this article, E-mail: mroth@fredhutch.org Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Changes in Temperature Management of Cardiac Arrest Patients Following Publication of the Target Temperature Management Trial

Objectives: To evaluate knowledge translation after publication of the target temperature management 33°C versus 36°C after out-of-hospital cardiac arrest trial and associated patient outcomes. Our primary hypothesis was that target temperature management at 36°C was rapidly adopted in Australian and New Zealand ICUs. Secondary hypotheses were that temporal reductions in mortality would be seen and would have accelerated after publication of the target temperature management trial. Design: Retrospective cohort study (January 2005 to December 2016). Setting: The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation adult patient database containing greater than 2 million admission episodes from 186 Australian and New Zealand ICUs. Patients: Sixteen-thousand two-hundred fifty-two adults from 140 hospitals admitted to ICU after out-of-hospital cardiac arrest. Interventions: The primary exposure of interest was admission before versus after publication of the target temperature management trial. Measurements and Main Results: The primary outcome variable to evaluate changes in temperature management was lowest temperature in the first 24 hours in ICU. The primary clinical outcome variable of interest was inhospital mortality. Secondary outcomes included proportion of patients with fever in the first 24 hours in ICU. Mean ± SD lowest temperature in the first 24 hours in ICU in pre- and posttarget temperature management trial patients was 33.80 ± 1.71°C and 34.70 ± 1.39°C, respectively (absolute difference, 0.98°C [99% CI, 0.89–1.06°C]). Inhospital mortality rate decreased by 1.3 (99% CI, –1.8 to –0.9) percentage points per year from January 2005 until December 2013 and increased by 0.6 (99% CI, –1.4 to 2.6) percentage points per year from January 2014 until December 2016 (change in slope 1.9 percentage points per year [99% CI, –0.6 to 4.4]). Fever occurred in 568 (12.8%) of 4,450 pretarget temperature management trial patients and 853 (16.5%) of 5,184 posttarget temperature management trial patients (odds ratio, 1.35 [99% CI, 1.16–1.57]). Conclusions: The average lowest temperature of postcardiac arrest patients in the first 24 hours in ICU rose after publication of the target temperature management trial. This change was associated with an increased frequency of fever not seen in the target temperature management trial. Members of the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS-CORE) are listed in the supplementary materials (Supplemental Digital Content 1, https://ift.tt/2viq6nq). Drs. Bailey and Young had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Salter and Young drafted the article. Dr. Bailey analyzed the statistical data. Dr. Goodwin developed the dynamic data visualization. Dr. Young conceptualized and designed the study and obtained funding. All authors acquired, analyzed, or interpreted the data and critically revised the article for important intellectual content. 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). This study was completed during the tenure of a Clinical Practitioner Fellowship funded by the Health Research Council of New Zealand held by Dr. Young. The Medical Research Institute of New Zealand is funded by independent research organization funding from the Health Research Council of New Zealand. Dr. Nielsen received funding from Bard Medical (lecture fees) and Braincool Advisory board. Dr. Nichol disclosed that he is supported by the Health Research Board of Ireland Clinical Trial Network funding. Dr. Saxena’s institution received funding for article research from the National Health and Medical Research Council Early Career Fellowship and Bard Medical (consultancy and invited lectures). Intensive Care Foundation Project Grant. Dr. Young received funding from Bard Medical for lecture fees. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: paul.young@ccdhb.org.nz Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Issue Information

Academic Emergency Medicine, Volume 25, Issue 7, Page 711-715, July 2018.


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A Case‐Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females with Pelvic Pain

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


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Urachal Remnants in Patients Presenting to the Emergency Department with Abdominal Pain

Publication date: Available online 30 July 2018

Source: The Journal of Emergency Medicine

Author(s): Jonathan S. Schiffman

Abstract

Background

Rare causes of abdominal pain include abnormalities of the urachus, including patent urachus and urachal cyst with or without infection. However, reviews discussing etiology of abdominal pain, even in children, may completely omit mention of urachal remnants.

Objectives

Determine the incidence of symptomatic urachal remnants in patients presenting to the emergency department (ED), including common presenting findings and method of diagnosis.

Methods

A retrospective chart review was performed of all patients presenting to the ED with abdominal pain who were diagnosed with urachal remnants, including patent urachus or urachal cyst or abscess over a period of 11 years and 7 months in one hospital.

Results

There were a total of 833,317 ED visits over the time period of the chart review, with 76,954 patients or 9.2% presenting with a complaint of abdominal pain. Twenty-four patients were identified, or 0.03% of those presenting with abdominal pain. Ages ranged from 16 days to 59 years. Among those 18 years or older, there was a male-to-female ratio of 1:1 of 14 patients. Thirteen patients (54.2%) initially presented with drainage from the umbilicus.

Conclusions

Although rare, symptomatic disorders of urachal remnants may present at any age. These disorders should be kept in mind by the emergency physician among the broad list of differential diagnoses accounting for abdominal pain. Urachal cyst and abscess may present with or without drainage from the umbilicus. Drainage from the umbilicus is highly suggestive, but not pathognomonic, of a urachal anomaly, and patients should be imaged to make a definite diagnosis and assist in the management plan.

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The future of utility meets durability in latest CORDURA® + Carhartt collaboration

WICHITA, KS — INVISTA's CORDURA® brand and Carhartt announce the latest collaboration in their long-standing partnership with the launch of Carhartt's newest generation Full Swing® Steel line, a dynamic workwear collection designed and developed through an extensive consumer insight program. The collection consists of a Men's Full Swing® Steel Jacket, Full Swing®...

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Winners of Inaugural Poster Session announced

LAKEVILLE, Minn. — ImageTrend, Inc. is pleased to announce the winners of the Inaugural Poster Session from ImageTrend Connect 2018. The posters were fitting in theme with the conference topics of using data to improve patient care, public safety and operational efficiencies. Participants demonstrated what they are doing to make an impact within their community using original research,...

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Tox and Hound – The Ethics & Etiquette of Just Standing There

by Andrew Stolbach       This is one of two related, and complementary posts as part of a special series about ethanol in the ER. The first part can be found here. Old-fashioned physician wisdom teaches us everything we need to know about managing intoxicated patients. I have a cloth-bound edition of Austin Flint’s […]

EMCrit Project by Tox & Hound.

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Tox and Hound – The Birds and the (Mellan)bys

by Howard Greller     This is one of two related, and complementary posts as part of a special series about ethanol in the ER. The second part can be found here. It was the end of the first World War. In a small corner of England, Sir Dr. Edward Mellanby (Doctor Sir?) performed one […]

EMCrit Project by Tox & Hound.

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Tox and Hound – The Ethics & Etiquette of Just Standing There

by Andrew Stolbach       This is one of two related, and complementary posts as part of a special series about ethanol in the ER. The first part can be found here. Old-fashioned physician wisdom teaches us everything we need to know about managing intoxicated patients. I have a cloth-bound edition of Austin Flint’s […]

EMCrit Project by Tox & Hound.

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Tox and Hound – The Birds and the (Mellan)bys

by Howard Greller     This is one of two related, and complementary posts as part of a special series about ethanol in the ER. The second part can be found here. It was the end of the first World War. In a small corner of England, Sir Dr. Edward Mellanby (Doctor Sir?) performed one […]

EMCrit Project by Tox & Hound.

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Antiretroviral drugs for treatment and prevention of HIV infection in adults 2018: Recommendations of the International Antiviral Society–USA Panel

JAMA

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Frequency, predictors, and outcomes of prehospital and early postarrival neurological deterioration in acute stroke: Exploratory analysis of the FAST-MAG randomized clinical trial

JAMA Neurology

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PulmCrit- Can we fix a broken circadian clock with melatonin?

Circadian rhythms and melatonin are best known for their relationship to sleep.  However, they have a much broader range of functions.  Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).  

EMCrit Project by Josh Farkas.

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PulmCrit- Can we fix a broken circadian clock with melatonin?

Circadian rhythms and melatonin are best known for their relationship to sleep.  However, they have a much broader range of functions.  Circadian rhythms cause many organs to enter a resting state at night (e.g. heart rate decreases, cortisol levels increase).  

EMCrit Project by Josh Farkas.

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Machine Learning Without Borders? An Adaptable Tool to Optimize Mortality Prediction in Diverse Clinical Settings

Background Mortality prediction aids clinical decision-making and is necessary for quality improvement initiatives. Validated metrics rely on pre-specified variables and often require advanced diagnostics which are unfeasible in resource-constrained contexts. We hypothesize that machine learning will generate superior mortality prediction in both high-income and low and middle-income country cohorts. Methods SuperLearner(SL), an ensemble machine-learning algorithm, was applied to data from three prospective trauma cohorts: a highest-activation cohort in the United States(US), a high-volume center cohort in South Africa(SA), and a multicenter registry in Cameroon. Cross-validation was used to assess model discrimination of discharge mortality by site using receiver operating characteristic curves. SuperLearner discrimination was compared with standard scoring methods. Clinical variables driving SL prediction at each site were evaluated. Results Data from 28,212 injured patients were used to generate prediction. Discharge mortality was 17%, 1.3%, and 1.7% among US, SA, and Cameroonian cohorts. SL delivered superior prediction of discharge mortality in the US (AUC 94-97%) and vastly superior prediction in Cameroon (AUC 90-94%) compared to conventional scoring algorithms. It provided similar prediction to standard scores in the SA cohort (AUC 90-95%). Context-specific variables (partial thromboplastin time in the US and hospital distance in Cameroon) were prime drivers of predicted mortality in their respective cohorts, while severe brain injury predicted mortality across sites. Conclusions Machine learning provides excellent discrimination of injury mortality in diverse settings. Unlike traditional scores, data-adaptive methods are well-suited to optimizing precise site-specific prediction regardless of diagnostic capabilities or dataset inclusion allowing for individualized decision-making and expanded access to quality improvement programming. Level of Evidence Level III Study Type Prognostic and Therapeutic Corresponding author: Catherine Juillard MD MPH, 1001 Potrero Ave, 3A, San Francisco, CA 94110, Phone: 415-206-4622, Fax: (415) 206-5484, Email: CatherineJuillard@ucsf.edu Conflicts of interest: For all authors, no conflicts of interest declared. Meetings: Podium Presentation at 48th Annual Meeting of the Western Trauma Association, February 25-March 3, 2018 in Whistler, British Columbia. Funding: Supported by PCORI R-IMC-1306-02735 (MJC), NIH #K01ES026834 (RAC). © 2018 Lippincott Williams & Wilkins, Inc.

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Hidden Burden of Venous Thromboembolism After Trauma: A National Analysis

Background Trauma patients are at increased risk for venous thromboembolism (VTE). One in four trauma readmissions occur at a different hospital. There are no national studies measuring readmissions to different hospitals with VTE following trauma. Thus, the true national burden in trauma patients readmitted with VTE is unknown and can provide a benchmark to improve quality of care. Methods The Nationwide Readmission Database (2010-2014) was queried for patients ≥18 years non-electively admitted for trauma. Patients with VTE or IVC filter placement on index admission were excluded. Outcomes included 30-day and 1-year readmission to both index and different hospitals with a new diagnosis of VTE. Multivariable logistic regression identified risk factors. Results were weighted for national estimates. Results Of the 5,151,617 patients admitted for trauma, 1.2% (n=61,800) were readmitted within one year with VTE. Of those, 29.6% (n=18,296) were readmitted to a different hospital. Risk factors for readmission to a different hospital included: index admission to a for-profit hospital (OR 1.33 [1.27-1.40], p7 days (OR 1.12 [1.07-1.18], p

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Safety of Early Tracheostomy in Trauma Patients After Anterior Cervical Fusion

Background Cervical spine injuries (CSI) can have major effects on the respiratory system and carry a high incidence of pulmonary complications. Respiratory failure can be due to spinal cord injuries, concomitant facial fractures or chest injury, airway obstruction, or cognitive impairments. Early tracheostomy (ET) is often indicated in patients with CSI. However, in patients with anterior cervical fusion (ACF), concerns about cross-contamination often delay tracheostomy placement. This study aims to demonstrate the safety of ET within four days of ACF Methods Retrospective chart review was performed for all trauma patients admitted to our institution between 2001-2015 with diagnosis of CSI who required both ACF and tracheostomy, +/- posterior cervical fusion (PCF), during the same hospitalization. 39 study patients with ET (within four days of ACF) were compared to 59 control patients with late tracheostomy (LT) (5-21 days after ACF). Univariate and logistic regression analyses were performed to compare risk of wound infection, length of ICU and hospital stay, and mortality between both groups during initial hospitalization. Results There was no difference in age, sex, pre-existing pulmonary or cardiac conditions, Glasgow Comas Scale (GCS), Injury Severity Score, Chest Abbreviated Injury Scale, American Spinal Injury Association (ASIA) score, CSCI levels, and tracheostomy technique between both groups. There was no statistically significant difference in surgical site infection between both groups. There were no cases of cervical fusion wound infection in the ET group (0%), but five cases (8.47%) in the LT group (p=0.15). 4 involved the PCF wound and 1, the ACF wound. There was no statistically significant difference in ICU stay (p=0.09), hospital stay (p=0.09), or mortality (p=0.06) between groups. Conclusion Early tracheostomy within four days of ACF is safe without increased risk of infection compared to late tracheostomy. Level of evidence This study represents level III evidence. Corresponding: Claudia Patricia Lozano Guzman, MD, General Surgery Residency: Beth Israel Deaconess Medical Center. Surgical Critical Care Fellowship: Sidney Kimmel Medical College at Thomas Jefferson University. Email: Claudia.Lozano.Bidmc@gmail.com, Address: 1100 Walnut Street. Suite 702. Philadelphia, PA. 19107. Phone: 617 301 2624, Fax: 215 923 7957 Conflict of Interest I have no conflict of interest, I have no financial support of any kind including pharmaceutical and industrial. I received no funding or support from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; and the Howard Hughes Medical Institute (HHMI). Presentations This study was presented at the 75th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 14-17, 2016, Waikoloa, Hawaii. © 2018 Lippincott Williams & Wilkins, Inc.

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Vitamin C in Burns, Sepsis, and Trauma

No abstract available

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Citrated Kaolin Thrombelastography (TEG) Thresholds for Goal-Directed Therapy in Injured Patients Receiving Massive Transfusion

Introduction Goal-directed hemostatic resuscitation based on thrombelastography (TEG) has a survival benefit compared to conventional coagulation assays such as INR, aPTT, fibrinogen level, and platelet count. While TEG-based transfusion thresholds for patients at risk for massive transfusion (MT) have been defined using rapid TEG (rTEG), cutoffs have not been defined for TEG using other activators such as kaolin. The purpose of this study was to develop thresholds for blood product transfusion using citrated kaolin TEG (CK-TEG) in patients at risk for MT. Methods CK-TEG was assessed in trauma activation patients at two level-one trauma centers admitted between 2010-2017. ROC curve analyses were performed to test the predictive performance of CK-TEG measurements in patients requiring MT, defined as >10 units of RBC or death within the first 6 hours. The Youden Index defined optimal thresholds for CK-TEG-based resuscitation. Results Of the 825 trauma activations, 671 (81.3%) were male, 419 (50.8%) suffered a blunt injury, and 62 (7.5%) received a MT. Patients who had a MT were more severely injured, had signs of more pronounced shock, and more abnormal coagulation assays. CK-TEG R-Time was longer (4.9vs4.4 min, p=0.0084), Angle was lower (66.2vs70.3 degrees, p4.45 min. Angle had an AUROC=0.6931, and a 4 cut point of4.55%. Conclusions We have identified CK-TEG thresholds that can guide MT in trauma. We propose plasma transfusion for R-time > 4.45 min, fibrinogen products for an angle 4.55%. Level of Evidence Therapeutic study, level V Study Type Prognostic and Therapeutic Corresponding Author: Ernest E Moore, MD, Email: ernest.moore@dhha.org Phone: 303-724-2685 Fax: 303-720-2682, Mailing Address: 655 Bannock Street Denver, CO 80203 Author Contact Information: Gregory Stettler: gregory.stettler@ucdenver.edu Joshua Sumislawski: joshua.sumislawski@ucdenver.edu Ernest E Moore: ernest.moore@dhha.org Geoffrey R Nunns: Geoffrey.nunns@ucdenver.edu Lucy Z Kornblith: Lucy.Kornblith@ucsf.edu Amanda S Conroy: Amanda.Conroy@ucsf.edu Rachael A Callcut: Rachael.Callcut@ucsf.edu Christopher C Silliman: christopher.silliman@ucdenver.edu Anirban Banerjee: anirban.banerjee@ucdenver.edu Mitchell J Cohen: mitchell.cohen@ucdenver.edu Angela Sauaia: angela.sauaia@ucdenver.edu Disclosure: Research reported in this publication was supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, the Department of Defense USAMRAA, W81XWH-12-2-0028, and W911QY-15-C-0044, in addition to the National Institute of Environmental Health Sciences K01ES026834. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support provided by Haemonetics with shared intellectual property. © 2018 Lippincott Williams & Wilkins, Inc.

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Association Between Transfusion of RBCs and Subsequent Development of Delirium in Critically Ill Children

Objectives: To determine the temporal relationship between the transfusion of RBCs and the subsequent development of delirium in a cohort of critically ill children. Design: Nested retrospective cohort study within prospective cohort study. Setting: Urban academic tertiary care PICU. Patients: All consecutive admissions from September 2014 through August 2015. Interventions: Children were screened twice daily for delirium during their PICU admission. Measurements and Main Results: Among 1,547 independent admissions screened for delirium, 166 (10.7%) were transfused RBCs. Children who were transfused RBCs were more than twice as likely to be delirious during their admission compared with children who were never transfused, after controlling for known predictors of delirium development (adjusted odds ratio, 2.16; 95% CI, 1.38–3.37; p = 0.001). Among transfused children, a temporal relationship was observed between receipt of RBCs and the subsequent development of delirium. For each additional 10 mL/kg of RBCs transfused, the recipients were 90% more likely to develop delirium or coma in the 72 hours following the transfusion, after controlling for confounders (adjusted odds ratio, 1.90; 95% CI, 1.14–3.17; p = 0.01). Anemia (represented by nadir hemoglobin prior to transfusion) was not associated with delirium development. Conclusions: In this cohort of critically ill children, there is an independent association between the receipt of an RBC transfusion and the subsequent development of delirium. Further prospective studies are warranted to replicate this finding and investigate possible pathophysiologic mechanisms for this association. Supported, in part, by the Empire Clinical Research Investigator Program and the Clinical Translational Science Center, grant number UL1-TR000457-06. Dr. Traube received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: man9026@med.cornell.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients

Objectives: To determine and quantify risk factors for postoperative pediatric delirium. Design: Single-center prospective cohort study. Setting: Twenty-two bed PICU in a tertiary care academic medical center in Germany. Patients: All children admitted after major elective surgery (n = 93; 0–17 yr). Interventions: After awakening, children were screened for delirium using the Cornell Assessment of Pediatric Delirium bid over a period of 5 days. Demographic and clinical data were collected from the initiation of general anesthesia. Measurements and Main Results: A total of 61 patients (66%) were delirious. Younger children developed delirium more frequently, and the symptoms were more pronounced. The number of preceding operations did not influence the risk of delirium. Total IV anesthesia had a lower risk than inhalational anesthesia (p

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Quality Improvement Bedside Rounding Audits Enhance Protein Provision for Pediatric Patients Receiving Continuous Renal Replacement Therapy

Objectives: Describe quality improvement process improvements in protein delivery of continuous renal replacement therapy initiation. Design: Prospective study. Setting: PICU and cardiovascular ICU within a quaternary care children’s hospital. Patients: PICU and cardiovascular ICU patients receiving continuous renal replacement therapy for greater than 48 hours. Inborn errors of metabolism were excluded. Interventions: Plan-Do-Study-Act cycles were initiated. Cycle 1 developed interdisciplinary quality improvement group continuously monitoring nutrition care with thrice weekly bedside safety rounds and protein prescriptions within nephrologist’s notes. Cycle 2 included education to intensivists. Cycle 3 initiated monthly quality improvement meetings reviewing nutritional care goals. Measurements and Main Results: Primary outcome was percentage of time patients met protein goals in the first 5 days of continuous renal replacement therapy. Secondary outcome was percentage of time patients met protein goals for duration of continuous renal replacement therapy. Cohort (n = 55) mean age was 8.1 years (SD ± 6.8), 62% male, and 31% malnutrition at baseline. Percent of time meeting protein goals by day 5 was 22%, 33%, and 71% and percent of time meeting protein goals throughout was 35%, 39%, and 75% of groups 1, 2, and 3, respectively. Significant improvement occurred after Plan-Do-Study-Act 3 (group 2 vs group 3; p

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An Analysis of Risk Factors for Hemolysis in Children on Extracorporeal Membrane Oxygenation

Objectives: Hemolysis is a known complication of pediatric extracorporeal membrane oxygenation associated with renal failure and mortality. We sought to identify predictors of hemolysis in pediatric extracorporeal membrane oxygenation patients and determine its influence on outcomes. Design: Retrospective, single-center study. Setting: Urban, quaternary care center pediatric and neonatal ICU. Patients: Ninety-six patients requiring extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: Daily measurements of plasma-free hemoglobin were obtained while patients were on extracorporeal membrane oxygenation. Patients with a prior extracorporeal membrane oxygenation run, on extracorporeal membrane oxygenation for less than 24 hours, or without complete medical records were excluded from the study. Ninety-six patients met inclusion criteria, of which, 25 patients (26%) had plasma-free hemoglobin greater than 30 mg/dL. Of those patients, 15 of 25(60%) had plasma-free hemoglobin greater than 50 mg/dL, and 21 of 25(84%) occurred during the first 7 days on extracorporeal membrane oxygenation. Compared with patients without hemolysis, those with hemolysis were younger (0.2 mo [0.06–3.2 mo] vs 8.2 mo [0.6–86 mo]; p 30 mg/dL) had a 10-fold increase in in-hospital mortality. In our study cohort, hemolysis was associated with continuous ultrafiltration use, but not continuous renal replacement therapy. Additionally, our results suggest that the degree of coagulopathy (international normalized ratio > 3.5) at the time of cannulation influences hemolysis. Additional prospective studies are necessary to define further strategies to prevent hemolysis and improve outcomes in pediatric extracorporeal membrane oxygenation patients. This work was performed at Columbia University Herbert and Florence Irving Medical Center, Morgan-Stanley Children’s Hospital of New York-Presbyterian. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: so2462@cumc.columbia.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Cognitive and Behavioral Consequences of Pediatric Delirium: A Pilot Study

Objectives: To investigate the long-term impact of postoperative delirium in children. Design: Single-center point prevalence study. Setting: Twenty-two bed PICU. Patients: Forty-seven patients 1–16 years old. Interventions: Standardized neuropsychologic follow-up investigation after a mean time of 17.7 ± 2.9 months after PICU discharge. Measurements and Main Results: Pediatric delirium did not have significant long-term impact on global cognition, executive functions, or behavior. Severity of delirium did not influence the outcome. Different predictors were identified for later cognitive functioning, executive functions, and behavioral problems. Younger age was confirmed to be a relevant risk factor for delirium as well as for the cognitive and behavioral outcome. Conclusions: Contrary to the findings in adults, there was no clear association between pediatric delirium and long-term cognition or behavior in this cohort. However, this is a first pilot study with several limitations that should promote more comprehensive prospective trials. Dr. Ries’ institution received funding from Shire (research grant), and he received funding from Alexion, Oxyrane, and GlaxoSmithKline. Dr. von Haken received funding from Orionpharma. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jochen.meyburg@med.uni-heidelberg.de ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Association Between Body Weight Variation and Survival and Other Adverse Events in Critically Ill Patients With Shock: A Multicenter Cohort Study of the OUTCOMEREA Network

Objectives: This study in critically ill patients with shock assessed the prognostic value of body weight variations occurring each day from day 3 to day 7 on the 30-day outcome in terms of mortality, occurrence of ventilator-associated pneumonia and of bedsore, and occurrence of length of stay . Design: Retrospective analysis of data. Multivariate subdistribution survival models were used at each day, from day 3 to day 7. The impact of body weight variations on length of stay was estimated through a multivariate negative binomial regression model. Setting: Prospective multicenter cohort study. Patients: Critically ill patients admitted in ICU with shock and requiring mechanical ventilation within 48 hours. Intervention: None. Measurements and Main Results: Two-thousand three-hundred seventy-four patients were included. Their median body weight variations increased from 0.4 kg (interquartile range, 0–4.8 kg) on day 3 to 3 kg (interquartile range, –0.4 to 8.2 kg) on day 7. Categories of body weight variations were defined depending on body weight variations interquartiles: weight loss, no weight gain, moderate and severe weight gain. A severe weight gain tended to be associated with death at days 5 and 6 (day 5: subdistribution hazard ratio, 1.27; 95% CI, 0.99–1.63; p = 0.06 and day 6: subdistribution hazard ratio, 1.43; 95% CI, 1.08–1.89; p = 0.01), a weight loss tended to be associated with bedsore, and a severe gain between at days 5 and 6 was associated with ventilator-associated pneumonia. Any body weight variations were associated with an increased length of stay. Conclusions: In survivors at day 3, body weight variations during the first days of ICU stay might be a clinically relevant tool to prevent weight gain but also for prognostication of 30-day mortality, occurrence of ventilator-associated pneumonia, and occurrence of prolonged ICU stay. Drs. Gros and Dupuis contributed equally to the article as co-first authors. Members of the OUTCOMEREA Study Group are listed in the Acknowledgments. 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 OUTCOMEREA study group (Aulnay ss bois, France). Dr. Azoulay’s institution received research support from Alexion, Fisher & Payckle, Gilead, Jazz Pharma, Ablynx, and Astellas, and he received funding from lectures for Alexion, Gilead, Baxter, and Merck. Dr. Darmon received other support outside the submitted work from Merck (research grant, speaker fees, and support in organizing educational meetings), Astute medical (research grant), Astellas (speaker fees and support in organizing educational meetings), Bristol Myers Squibb (speaker fees), JazzPharma (support in organizing educational meetings), and Sanofi-Aventis (advisory board). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Jean-francois.timsit@aphp.fr Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

Objectives: To identify the key points for improving severe maternal morbidity by analyzing pregnancy-related ICU admissions in Beijing. Design: This was a retrospective, multicenter cohort study. Setting: Three ICUs in tertiary hospitals in Beijing. Patients: A total of 491 severe maternal cases in any trimester of pregnancy or within 42 days of delivery were reviewed between January 1, 2008, and December 31, 2016. Interventions: None. Measurements and Main Results: Among 491 obstetric ICU admissions (median Sequential Organ Failure Assessment score, 2) out of 87,850 hospital deliveries (a frequency of 5.6 admissions per 1,000 deliveries), the leading diagnoses were postpartum hemorrhage (170; 34.62%), hypertensive disorders of pregnancy (156; 31.77%), and cardio-cerebrovascular diseases (78; 15.9%). Comparing 2008–2011 to 2012–2016, the rates of maternal mortality (2.5% vs 1.9%; p = 0.991) and fetal loss (8.5% vs 8.6%; p = 0.977) did not decrease significantly, whereas the rates of ICU admission (3.05% vs 7.85%; p trends

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Is it time to pull epinephrine from the EMS formulary?

Our co-hosts discuss a recent study out of the UK that puts the use of epinephrine in prehospital cardiac arrest patients into question

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A Novel Expeditionary Perfused Cadaver Model for Trauma Training in the Out-of-Hospital Setting

Publication date: Available online 29 July 2018

Source: The Journal of Emergency Medicine

Author(s): Theodore T. Redman, Elliot M. Ross

Abstract

Background

Cadaver training for prehospital surgical procedures is a valid training model. The limitation to date has been that perfused cadavers have only been used in wet laboratories in hospitals or university centers. We endeavor to describe a transportable central-perfused cadaver model suitable for training in the battlefield environment. Goals of design were to create a simple, easily reproducible, and realistic model to simulate procedures in field and austere conditions.

Methods

We conducted a review of the published literature on cadaver models, conducted virtual-reality simulator training, performed interviews with subject matter experts, and visited the laboratories at the Centre for Emergency Health Sciences in Spring Branch, TX, the Basic Endovascular Skills in Trauma laboratory in Baltimore, MD, and the Fresh Tissue Dissection Laboratory at Los Angeles County and University of Southern California, Keck School of Medicine, Los Angeles, CA.

Procedure

This article will describe a five-step procedure that utilizes extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures. The model will then be ready for all tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations.

Conclusions

This model has been used in the laboratory, field, ground ambulance, and military air ambulance (UH-60) settings with good results. The model described can be used in the field setting with minimal resources and accurately simulates the critical skills for all combat trauma procedures.

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EMCrit – When it comes to Preintubation Terminology we stink like POO

What we have here is a failure to communicate

EMCrit Project by Scott Weingart.

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EMCrit – When it comes to Preintubation Terminology we stink like POO

What we have here is a failure to communicate

EMCrit Project by Scott Weingart.

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Applying Artificial Intelligence to Identify Physiomarkers Predicting Severe Sepsis in the PICU

Objectives: We used artificial intelligence to develop a novel algorithm using physiomarkers to predict the onset of severe sepsis in critically ill children. Design: Observational cohort study. Setting: PICU. Patients: Children age between 6 and 18 years old. Interventions: None. Measurements and Main Results: Continuous minute-by-minute physiologic data were available for a total of 493 critically ill children admitted to a tertiary care PICU over an 8-month period, 20 of whom developed severe sepsis. Using an alert time stamp generated by an electronic screening algorithm as a reference point, we studied up to 24 prior hours of continuous physiologic data. We identified physiomarkers, including SD of heart rate, systolic and diastolic blood pressure, and symbolic transitions probabilities of those variables that discriminated severe sepsis patients from controls (all other patients admitted to the PICU who did not meet severe sepsis criteria). We used logistic regression, random forests, and deep Convolutional Neural Network methods to derive our models. Analysis was performed using data generated in two windows prior to the firing of the electronic screening algorithm, namely, 2–8 and 8–24 hours. When analyzing the physiomarkers present in the 2–8 hours analysis window, logistic regression performed with specificity of 87.4% and sensitivity of 55.0%, random forest performed with 79.6% specificity and 80.0% sensitivity, and the Convolutional Neural Network performed with 83.0% specificity and 75.0% sensitivity. When analyzing physiomarkers from the 8–24 hours window, logistic regression resulted in 77.1% specificity and 39.3% sensitivity, random forest performed with 82.3% specificity and 61.1% sensitivity, whereas the Convolutional Neural Network method achieved 81% specificity and 76% sensitivity. Conclusions: Artificial intelligence can be used to predict the onset of severe sepsis using physiomarkers in critically ill children. Further, it may detect severe sepsis as early as 8 hours prior to a real-time electronic severe sepsis screening algorithm. 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. West received funding from Learn4Life (board member). Dr. Davis received funding from GlaxoSmithKline. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: rkamales@uthsc.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Accurate Prediction of Congenital Heart Surgical Length of Stay Incorporating a Procedure-Based Categorical Variable

Objectives: There is increasing demand for the limited resource of Cardiac ICU care. In this setting, there is an expectation to optimize hospital resource use without restricting care delivery. We developed methodology to predict extended cardiac ICU length of stay following surgery for congenital heart disease. Design: Retrospective analysis by multivariable logistic regression of important predictive factors for outcome of postoperative ICU length of stay greater than 7 days. Setting: Cardiac ICU at Boston Children’s Hospital, a large, pediatric cardiac surgical referral center. Patients: All patients undergoing congenital heart surgery at Boston Children’s Hospital from January 1, 2010, to December 31, 2015. Interventions: No study interventions. Measurements and Main Results: The patient population was identified. Clinical variables and Congenital Heart Surgical Stay categories were recorded based on surgical intervention performed. A model was built to predict the outcome postoperative ICU length of stay greater than 7 days at the time of surgical intervention. The development cohort included 4,029 cases categorized into five Congenital Heart Surgical Stay categories with a C statistic of 0.78 for the outcome ICU length of stay greater than 7 days. Explanatory value increased with inclusion of patient preoperative status as determined by age, ventilator dependence, and admission status (C statistic = 0.84). A second model was optimized with inclusion of intraoperative factors available at the time of postoperative ICU admission, including cardiopulmonary bypass time and chest left open (C statistic 0.87). Each model was tested in a validation cohort (n = 1,008) with equivalent C statistics. Conclusions: Using a model comprised of basic patient characteristics, we developed a robust prediction tool for patients who will remain in the ICU longer than 7 days after cardiac surgery, at the time of postoperative ICU admission. This model may assist in patient counseling, case scheduling, and capacity management. Further examination in external settings is needed to establish generalizability. 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). Supported, in part, by the Rochelle E. Rose Cardiac ICU Research Funds. Boston Children’s Heart Center resources were used. Dr. Alexander’s institution received funding from Novartis (paid for work on clinical trial) and Tenax Therapeutics (supplies levosimendan to her institution at no cost for use in an Expanded Access Study). Mr. Mathieu disclosed work for hire. Dr. Nathan disclosed other support from a National Institutes of Health K23 grant for another project. Dr. Mayer Jr’s institution received funding from Medtronic. Dr. Thiagarajan’s institution received funding from Bristol Myers Squibb and Pfizer. Dr. Bergersen received institutional funds from 480 Biomedical. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: peta.alexander@cardio.chboston.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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DFW airport emergency room takes off with innovative communication platform

The world’s first fully-equipped airport emergency room opened recently at the Dallas Fort Worth International Airport. Using state-of-the-art communication platform, Pulsara, the ED will be able to quickly exchange patient information, estimated time of arrival, and other data with local EMS to get critical patients treated sooner. These medical care facility projects at DFW are the...

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Fire dept. intern saves man’s life with newly-learned skills

Kaylee Mosley jumped into action to save a man who had driven into a wall by performing CPR, which she had just been certified in four days earlier

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Pinnacle EMS Quick Take: Why public safety leaders must have zero-tolerance for sexual misconduct

Police sergeant challenges and educates EMS leaders to do more to reduce the risk and occurrence of sexual harassment for all employees

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Pinnacle EMS Quick Take: Active shooter incident lessons learned for leaders

NFPA 3000 is a framework for preparing EMS agencies, fire departments, other responders and communities for active shooter incident response and recovery

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The International Public Safety Association announces open registration for its Fall 2018 Mass Casualty Incidents Symposium in Washington D.C.

GOODYEAR, Ariz. — The International Public Safety Association opened registration for its Fall 2018 Mass Casualty Incidents Symposium in Washington D.C. This timely and important event is a significant cross-disciplinary training opportunity for all public safety officials, from senior level executives to the first responders who arrive on-scene. The event will be held November 14 and 15,...

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The characteristics and outcomes of patients who make an emergency department visit for hypertension after use of a home or pharmacy blood pressure device

Annals of Emergency Medicine

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Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: A randomised trial

The Lancet

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Management of children presenting with low back pain to emergency department. A 7-year retrospective study

The American Journal of Emergency Medicine

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Medications that reduce emergency hospital admissions: An overview of systematic reviews and prioritisation of treatments

BMC Medicine

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Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection

Objective The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality. Patients and methods A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality. Results Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91). Conclusion The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. https://ift.tt/1hexVwJ Correspondence to Chih-Min Su, MD, PhD, Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123 Ta Pei Road, Niaosong District, Kaohsiung 833, Taiwan Tel: +886 77 317 123 x8415; fax: +886 7735 3815; e-mails: mitosu@gmail.com, mito@cgmh.org.tw Received January 22, 2018 Accepted May 21, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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A novel method to assess the severity and prognosis in crush syndrome by assessment of skin damage in hairless rats

Abstract

Purpose

Crush syndrome (CS), a serious medical condition characterised by damage to the muscle cells due to pressure, is associated with high mortality, even when patients receive fluid therapy during transit to the hospital or admission to the hospital. There is no standard triage approach for earthquake victims with crush injuries due to the scarcity of epidemiologic and quantitative data. We examined whether mortality can be predicted based on the severity of skin damage so that assess the severity and prognosis in crush syndrome by assessment of skin damage in hairless rats because we have previously observed that CS results in oedema and redness of the skin in rats.

Methods

Anaesthetised rats were subjected to bilateral hind limb compression [1 kg (mild) and 2 kg (severe) loads] with a rubber tourniquet for 5 h. The rats were then randomly divided into three groups: sham, mild CS, and severe CS.

Results

The mild and severe CS groups had mortality rates of 20 and 90%, respectively. The severe CS group demonstrated higher rates of hyperkalaemia, hypovolemic shock, acidosis, and inflammation. Skin damage was significantly worse in the severe CS group compared to the mild CS group. Skin damage showed good correlation with pathological severity.

Conclusions

Skin damage is a valid measure of transepidermal water loss and severity of CS. We suggest that these models may be useful to professionals who are not experienced in disaster management to identify earthquake victims at high risk of severe CS.

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Oxygenator Impact on Ceftaroline in Extracorporeal Membrane Oxygenation Circuits

Objectives: To determine the oxygenator impact on alterations of ceftaroline in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extracorporeal membrane oxygenation circuit including the Quadrox-i oxygenator (Maquet, Wayne, NJ). Design: Quarter-inch and 3/8-inch, simulated closed-loop extracorporeal membrane oxygenation circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. An one-time dose of ceftaroline was administered into the circuits, and serial pre- and postoxygenator concentrations were obtained at 5 minutes, 1-, 2-, 3-, 4-, 5-, 6-, and 24-hour time points. Ceftaroline was also maintained in a glass vial, and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation. Setting: A free-standing extracorporeal membrane oxygenation circuit. Patients: None. Intervention: Single dose administration of ceftaroline into closed-loop extracorporeal membrane oxygenation circuits prepared with and without an oxygenator in series with serial preoxygenator, postoxygenator, and reference samples obtained for concentration determination over a 24-hour study period. Measurements and Main Results: For the 1/4-inch circuit with an oxygenator, there was 79.8% drug loss preoxygenator and 82.5% drug loss postoxygenator at 24 hours. There was a statistically significant difference (p

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Venoarterial Extracorporeal Membrane Oxygenation Versus Conventional Therapy in Severe Pediatric Septic Shock

Objectives: The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy. Design: International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014. Setting: Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States. Patients: Children greater than 30 days old and less than 18 years old. Interventions: None. Measurements and Main Results: Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy (n = 120), survival to hospital discharge was 40%. With venoarterial extracorporeal membrane oxygenation (n = 44), survival was 50% (p = 0.25; CI, –0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial extracorporeal membrane oxygenation (Δ = 24%; p = 0.02; CI, 2.5–42%). Survival was significantly higher in patients who received high extracorporeal membrane oxygenation flows of greater than 150 mL/kg/min compared with children who received standard extracorporeal membrane oxygenation flows or no extracorporeal membrane oxygenation (82%, 43%, and 48%; p = 0.03; CI, 0.1–0.7 and p

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Pinnacle EMS 2018 Quick Take: The power of collaboration for EMS leaders

Jay Fitch, Ph.D., tells Pinnacle leaders that collaboration with colleagues and frenemies is critical to greater operational success

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Epidemiology and Costs of Sepsis in the United States—An Analysis Based on Timing of Diagnosis and Severity Level

Objectives: To characterize the current burden, outcomes, and costs of managing sepsis patients in U.S. hospitals. Design: A retrospective observational study was conducted using the Premier Healthcare Database, which represents ~20% of U.S. inpatient discharges among private and academic hospitals. Hospital costs were obtained from billing records per the cost accounting method used by each hospital. Descriptive statistics were performed on patient demographics, characteristics, and clinical and economic outcomes for the index hospitalization and 30-day readmissions. Setting: Sepsis patient hospitalizations, including inpatient, general ward, and ICU (intermediate and/or step-down). Patients: Adults over 18 years old with a hospital discharge diagnosis code of sepsis from January 1, 2010, to September 30, 2016. Interventions: None. This was a retrospective observational study of deidentified data. Measurements and Main Results: The final study cohort consisted of 2,566,689 sepsis cases, representing patients with a mean age of 65 years (50.8% female). Overall mortality was 12.5% but varied greatly by severity (5.6%, 14.9%, and 34.2%) for sepsis without organ dysfunction, severe sepsis, and septic shock, respectively. Costs followed a similar pattern increasing by severity level: $16,324, $24,638, and $38,298 and varied widely by sepsis present at admission ($18,023) and not present at admission ($51,022). Conclusions: The highest burden of incidence and total costs occurred in the lowest severity sepsis cohort population. Sepsis cases not diagnosed until after admission, and those with increasing severity had a higher economic burden and mortality on a case-by-case basis. Methods to improve early identification of sepsis may provide opportunities for reducing the severity and economic burden of sepsis in the United States. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. This research was conducted at Premier, Inc. Supported, in part, by Beckman Coulter, Inc. Drs. Paoli and Dr. Reynolds are both employees of and hold stock in Beckman Coulter, Inc./Danaher Corp. (parent company of Beckman Coulter). Dr. Sinha is an employee of Premier, Inc., which received funding to conduct the research project. Dr. Gitlin is an employee of BluePath Solutions, which received funding to conduct the research project, and his institution received funding from Danaher Corp., Diagnostics & Life Science Platforms. Drs. Sinha’s and Crouser’s institutions received funding from Beckman Coulter, Inc. Dr. Crouser has received support from Beckman Coulter, Inc. as a scientific consultant and as principal investigator of a clinical trial investigating a novel sepsis biomarker, and his institution also received funding from the National Institutes of Health and Foundation for Sarcoidosis Research Address requests for reprints to: Carly J. Paoli, PharmD, MPH, Global Health Economics & Reimbursement, Danaher Corp., Diagnostics & Life Science Platforms | Beckman Coulter, 250 S. Kraemer Blvd, Brea, CA 92822. E-mail: cjworden@beckman.com Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Assessment of Lung Aeration and Recruitment by CT Scan and Ultrasound in Acute Respiratory Distress Syndrome Patients

Objectives: Lung ultrasound is commonly used to evaluate lung morphology in patients with acute respiratory distress syndrome. Aim of this study was to determine lung ultrasound reliability in assessing lung aeration and positive end-expiratory pressure–induced recruitment compared with CT. Design: Randomized crossover study. Setting: University hospital ICU. Patients: Twenty sedated paralyzed acute respiratory distress syndrome patients: age 56 years (43–72 yr), body mass index 25 kg/m2 (22–27 kg/m2), and PaO2/FIO2 160 (113–218). Interventions: Lung CT and lung ultrasound examination were performed at positive end-expiratory pressure 5 and 15 cm H2O. Measurements and Main Results: Global and regional Lung Ultrasound scores were compared with CT quantitative analysis. Lung recruitment (i.e., decrease in not aerated tissue as assessed with CT) was compared with global Lung Ultrasound score variations. Global Lung Ultrasound score was strongly associated with average lung tissue density at positive end-expiratory pressure 5 (R2 = 0.78; p

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Pinnacle EMS Quick Take: Why transitions of care are an important patient safety opportunity

Transitions of care are critical opportunities to communicate patient assessment and treatment information to other healthcare providers

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Pinnacle EMS Quick Take: EMS leaders challenged ‘to make tomorrow better than today’

John O'Leary, a survivor of 100 percent TBSA burn as a child, delivered an inspiring opening keynote to Pinnacle EMS conference attendees

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Pinnacle EMS Quick Take: Why transitions of care are an important patient safety opportunity

Transitions of care are critical opportunities to communicate patient assessment and treatment information to other healthcare providers

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An Unusual Case of Severe Hemodynamic Compromise

Publication date: Available online 26 July 2018

Source: The Journal of Emergency Medicine

Author(s): Athanasia Pataka, Seraphim Kotoulas, Evangelia Panagiotidou, Sofia Akritidou, Katalin Fekete, Georgia Pitsiou, Basilis Bagalas, Ioannis Stanopoulos

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Autonomic Nervous System Activity for Risk Stratification of Emergency Patients With Pneumonia

Publication date: Available online 26 July 2018

Source: The Journal of Emergency Medicine

Author(s): Lars Mizera, Katharina Boehm, Martin Duckheim, Patrick Groga-Bada, Meinrad Gawaz, Christine S. Zuern, Christian Eick

Abstract

Background

Community-acquired pneumonia (CAP) causes appreciable morbidity and mortality in adults, especially in those ≥65 years of age. At hospital admission, an immediate and reliable risk assessment is necessary to detect patients with possible fatal outcome.

Objective

We aimed to evaluate markers of the autonomic nervous system based on an electrocardiogram to predict mortality in patients with CAP.

Methods

For this purpose, the deceleration capacity (DC) of heart rate was calculated in 253 patients who presented to the emergency department with CAP. The 30-day mortality rate was defined as the primary endpoint (PEP). The secondary endpoint was the total mortality within 180 days.

Results

PEP was reached in 33 patients (13%). The DC, measured in milliseconds, was significantly lower in patients who reached the PEP than in those who did not (2.3 ± 1.5 ms vs. 3.6 ± 2.3 ms, p = 0.004). The DC was also significantly lower in nonsurvivors than in survivors at the time of the secondary endpoint (2.3 ± 1.5 ms vs. 3.7 ± 2.4 ms, p < 0.001). Our results indicate that DC is an independent predictor of 30- and 180-day mortality.

Conclusion

DC was independently associated with death from CAP in our study. As a practical consequence, DC could be useful in triage decisions. Patients with certain high risks could benefit from adjuvant treatment and special medical attention.

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What Constitutes Truly Low Risk of Stroke?

Publication date: Available online 26 July 2018

Source: The Journal of Emergency Medicine

Author(s): Oscar M. Jolobe

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Red blood cell transfusion in patients with ST-elevation myocardial infarction: A meta-analysis of more than 21,000 patients

Netherlands Heart Journal

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Does initial temperature in the Emergency Department predict outcomes in patients admitted for sepsis?

The Journal of Emergency Medicine

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Antihistamine use and the risk of injurious falls or fracture in elderly patients: A systematic review and meta-analysis

Osteoporosis International

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Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial

Blood Advances

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Feasibility of continuous noninvasive arterial pressure monitoring in a prehospital setting, measurements during emergency transfer

Objectives In severely injured or acutely ill patients close monitoring of blood pressure (BP) can be crucial. At the prehospital scene and during transfer to hospital, the BP is usually monitored using intermittent oscillometric measurements with an upper arm cuff every 3–5 min. The BP can be monitored noninvasively and continuously using the continuous noninvasive arterial pressure (CNAP) device. In this study, we investigated the feasibility of a CNAP device in a prehospital setting. Patients and methods The study was an observational convenience study. The CNAP device was applied to the patient once in the ambulance and measurements were carried out during transfer to hospital. The primary object was the number of patients in whom the CNAP could monitor the BP continuously in a prehospital area en route to hospital. Results Fifty-nine patients were enrolled in this study. Fifty-four (92%) patients had their BP monitored continuously by the CNAP. The main reasons for missing data were a mean BP below the detectable range, reduced pulse wave caused by constricted arteries in the fingers, or patients’ excessive movements. The CNAP provided continuous measurements after a median of 164.5 s. No complications and no adverse events were observed. Conclusion Continuous measurement of the BP obtained by the CNAP device is feasible and safe in a prehospital setting under potentially difficult conditions. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. https://ift.tt/1hexVwJ Correspondence to Louise H. Hansen, MD, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense 5000, Denmark Tel: +45 6541 4943; e-mail: louise.houlberg.hansen@rsyd.dk Received February 11, 2018 Accepted May 28, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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#YouToo

Publication date: Available online 25 July 2018

Source: The Journal of Emergency Medicine

Author(s): P. Considine

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Mortality, risk factors and causes of death in Swedish patients with open tibial fractures - a nationwide study of 3, 777 patients

Open tibial fractures are serious, complicated injuries. Previous studies suggested an increased risk of death, however, this has not been studied in large population-based settings. We aimed to analyze mortal...

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Epinephrine and the Paramedic-2 trial: Is it time to pull our starting pitcher?

New research questions whether pharmacotherapy in cardiac arrest is effective at ROSC and long-term survival

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Paramedics FT & PT - Flight Training a Plus - Injury Care EMS

Injury Care EMS is a medical transportation company based in Boise, Idaho that operates 24 x 7. We are currently seeking skilled Paramedics. Pay is DOE. You may qualify for help with moving expenses and a signing bonus, depending on qualifications. Veterans and other military service personnel are encouraged to apply. We like to work hard and play hard. Does this sound like you" Medical benefits offered ...

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Why transitions of care are an important patient safety opportunity

Transitions of care are critical opportunities to communicate patient assessment and treatment information to other healthcare providers

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Epinephrine and the paramedic-2 trial: Is it time to pull our starting pitcher?

New research questions whether pharmacotherapy in cardiac arrest is effective at ROSC and long-term survival

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EMS leaders challenged ‘to make tomorrow better than today’

John O'Leary, a survivor of 100 percent TBSA burn as a child, delivered an inspiring opening keynote to Pinnacle EMS conference attendees

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Why transitions of care are an important patient safety opportunity

Transitions of care are critical opportunities to communicate patient assessment and treatment information to other healthcare providers

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Responders thank woman for paying breakfast bill

A woman left a note, simply signed “Recovering addict,” for a group of Toms River First Aid Squad members and paid their tab

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EMCrit Podcast 229 – No-Shitters, Boldface, and the Resus QRH

drum roll please...

EMCrit Project by Scott Weingart.

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Systems Concepts - Part 2 - Best Parts Do Not Make Best Systems

This vlog post is the second in a series about the concept of systems. It explores the systems design principle that having all of the best individually performing parts does not necessarily provide the best performing system. That concept is then applied to the example of systems of care for out-of-hospital cardiac arrest. Duration = 7 min 24 sec Link to CSI webpage

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Systems Concepts - Part 2 - Best Parts Do Not Make Best Systems

This vlog post is the second in a series about the concept of systems. It explores the systems design principle that having all of the best individually performing parts does not necessarily provide the best performing system. That concept is then applied to the example of systems of care for out-of-hospital cardiac arrest. Duration = 7 min 24 sec Link to CSI webpage

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EMCrit Podcast 229 – No-Shitters, Boldface, and the Resus QRH

drum roll please...

EMCrit Project by Scott Weingart.

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Effects of high-voltage electrical burns and other burns on levels of serum oxidative stress and telomerase in children

Burns

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Highly malignant routine EEG predicts poor prognosis after cardiac arrest in the Target Temperature Management trial

Resuscitation

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Serum lactate as a predictor of neurologic outcome in Emergency Department patients with acute carbon monoxide poisoning

The American Journal of Emergency Medicine

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Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium

Resuscitation

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National variation in opioid prescribing and risk of prolonged use for opioid-naive patients treated in the Emergency Department for ankle sprains

Annals of Emergency Medicine

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Non–coronary predictors of elevated high–sensitive cardiac Troponin T (hs – cTnT) levels in an unselected emergency patient cohort

Clinical Cardiology

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Using serial hemoglobin levels to detect occult blood loss in the early evaluation of blunt trauma patients

The Journal of Emergency Medicine

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Metabolic syndrome and its components as risk factors for prolonged QTc interval in apparently healthy Korean men and women

Journal of Clinical Lipidology

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The combined effect of cigarette smoking and fitness on injury risk in men and women

Nicotine & Tobacco Research

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Systems Concepts - Part 2 - Best Parts Do Not Make Best Systems

This vlog post is the second in a series about the concept of systems. It explores the systems design principle that having all of the best individually performing parts does not necessarily provide the best performing system. That concept is then applied to the example of systems of care for out-of-hospital cardiac arrest. Duration = 7 min 24 sec Link to CSI webpage

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Systems Concepts - Part 2 - Best Parts Do Not Make Best Systems

This vlog post is the second in a series about the concept of systems. It explores the systems design principle that having all of the best individually performing parts does not necessarily provide the best performing system. That concept is then applied to the example of systems of care for out-of-hospital cardiac arrest. Duration = 7 min 24 sec Link to CSI webpage

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Optimising emergency weight estimation in underweight and obese children: the accuracy of estimations of total body weight and ideal body weight

Objective During medical emergencies, underweight and obese children are at a higher risk of weight-estimation errors than ‘average’ children, which may lead to poorer outcomes. In obese children, optimum drug dosing requires a measure of both total body weight (TBW) and ideal body weight (IBW) for appropriate scaling. We evaluated the ability of the Broselow tape, the Mercy method and the PAWPER XL tape to estimate TBW and IBW in obese and underweight children. Participants and methods Data for children aged 0–18 years were extracted and pooled from three previous weight-estimation studies. The accuracy of estimation of TBW and IBW by each method was evaluated using percentage of estimations within 10% of target weight (PW10) as the primary outcome measure. Results The Broselow tape estimated TBW poorly in obese and underweight children (PW10: 3.9 and 41.4%), but estimated IBW extremely accurately (PW10: 90.6%). The Mercy method estimated TBW accurately in both obese and underweight children (PW10: 74.3 and 76.3%) but did not predict IBW accurately (PW10: 14.3%). The PAWPER XL tape predicted TBW well (PW10: 73.0% in obese children and 74.9% in underweight children) and predicted IBW extremely accurately (PW10: 100%). Conclusion The Broselow tape predicted IBW, but not TBW, accurately. The Mercy method estimated TBW very accurately, but not IBW. The PAWPER XL tape estimated both TBW and IBW accurately. The PAWPER XL tape should be considered when choosing a weight-estimation strategy for obese and underweight children. Correspondence to Mike Wells, MBBCh, MSc(Med), FCEM(SA), Postnet Suite 429, Private Bag X1510, Glenvista 2058, South Africa Tel: +27 824 910 369; fax: +27 66 591 631;e-mail: mike.wells@emergencymedicine.co.za Received December 20, 2017 Accepted June 29, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?

Publication date: Available online 24 July 2018

Source: The Journal of Emergency Medicine

Author(s): John E. Jesus, Kenneth D. Marshall, Chadd K. Kraus, Arthur R. Derse, Eileen F. Baker, Jolion McGreevy, American College of Emergency Physicians (ACEP) Ethics Committee

Abstract

Background

Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it.

Objectives

In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU.

Discussion

Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition.

Conclusions

End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients’ values and stated goals of care.

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Using Serial Hemoglobin Levels to Detect Occult Blood Loss in the Early Evaluation of Blunt Trauma Patients

Publication date: Available online 24 July 2018

Source: The Journal of Emergency Medicine

Author(s): Vikas Shahi, Varun Shahi, William R. Mower

Abstract

Background

Serial hemoglobin measurement (ΔHgb) is intended to aid in the early identification of blunt trauma patients who have significant blood loss requiring intervention. However, the utility of ΔHgb has yet to be rigorously studied.

Objective

We sought to determine if ΔHgb is a reliable diagnostic tool in assessing blood loss in blunt trauma patients.

Methods

We enrolled consecutive blunt trauma patients ≥18 years of age who presented to a level I trauma center. We measured 2 hemoglobin levels spaced 5 min apart and calculated the difference (ΔHgb) for each patient. We also recorded whether each patient required any of the following interventions to treat their injuries: 1) operation or procedure to control hemorrhage; 2) radiographic embolization; 3) administration of blood and blood products; 4) administration of ≥3 liters of intravenous fluids; and 5) exsanguination. Our primary outcome was the area under the receiver operating characteristic (ROC) curve.

Results

We enrolled 251 patients, including 192 males and 59 females with a mean age of 40 years. Interventions occurred in 56 patients and were withheld in 195. The median ΔHgb was −0.1 gm/dL (interquartile range −0.5 to 0.1 gm/dL) for patients requiring intervention and 0.0 gm/dL (interquartile range −0.6 to 0.3 gm/dL) for patients not requiring intervention. We found the area under the ROC curve to be 0.53 (95% confidence interval 0.44–0.62).

Conclusions

Our results indicated that ΔHgb does not reliably distinguish between blunt trauma patients who require intervention and those who do not.

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Dripped Lidocaine: A Novel Approach to Needleless Anesthesia for Mucosal Lacerations

Publication date: Available online 24 July 2018

Source: The Journal of Emergency Medicine

Author(s): Jillian Nickerson, Ee Tein Tay

Abstract

Background

Oral lacerations represent a unique challenge for anesthesia in the emergency department. Many options exist for local anesthesia, but these options are often associated with pain from injections or anxiety from anticipated needle injection.

Case Series

We introduce a novel and needleless approach to achieving local anesthesia for oral mucosa repair by dripping injectable lidocaine directly onto mucosal wounds prior to repair. This method is well tolerated and achieves appropriate anesthesia without undesirable side effects.

Why Should an Emergency Physician Be Aware of This?

Dripped injectable lidocaine may be an alternative method for mucosal anesthesia in the pediatric population.

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Ezras Nashim: EMS by women, for women

Brooklyn EMS volunteers offer services tailored to their New York community

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Streptococcal M1 protein induces hyporesponsiveness and cytokine release from human arteries in a fibrinogen-dependent manner: a translational study

Streptococcus pyogenes is a Gram positive bacterial species commonly involved in sepsis. Invasive strains express virulence factors such as the M1 protein. M1 protein forms complexes with fibrinogen leading to a ...

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EMT-B - Friendly Care Medical Transport

FULL/PART Time Positions Available. $15+ All shifts available. Highland Park, NJ. Please call 732-448-0100 for more information. Competitive pay and benefits. Job Purpose: Provides emergency medical support by responding to emergencies; stabilizing and transporting patients. Duties: - Prepares to transport patients by completing operator vehicle inspections; inventorying supplies; correcting deficiencies ...

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Nurse urges public to learn CPR after fatal vehicle crash

Lindsey Skebba said she stopped at the crash scene and noticed several bystanders had not started CPR on the victim, who later died

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Paramedic 12 HOUR SHIFT - Cabarrus County EMS

Hiring range for this position is $38,043.20 - 43,368.00. Initial placement for new employees is customarily at entry level through 25% percentile. Pay grade for this position is 14 Performs advanced technical work responding, rescuing, and transporting the sick and injured and administering emergency medical care at the paramedic level. Work is performed under the regular supervision of a Shift Supervisor ...

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Spotlight: 12 Lead Trainer features a wave generation algorithm that creates an EKG that simulates reality

12 Lead Trainer’s goal is to drastically improve the training process, providing rhythms like those you’d see in the field.

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Paramedic/Emergency Medical Services Instructor - Ozarks Technical Community College

**Date Position Available: **September 17, 2018 **Department: **Allied Health **FLSA: **Exempt **Immediate Supervisor: **Paramedic/Emergency Medical Services Program Director **Schedule Details: **Full-time/11 month position/PSRS **Position Summary** The Instructor will be responsible for the instruction and management of assigned classes and will maintain professionalism within their specialized field ...

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Does the quality of preoperative closed reduction of displaced ankle fractures affect wound complications after surgical fixation?

Injury

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Prognostic value of sLOX-1 level in acute coronary syndromes based on thrombolysis in myocardial infarction risk score and clinical outcome

The Journal of Emergency Medicine

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A simplified formula discriminating subtle anterior wall myocardial infarction from normal variant ST-segment elevation

American Journal of Cardiology

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Bleeding events after ST-segment elevation myocardial infarction in patients randomized to an all-comer clinical trial compared with unselected patients

American Journal of Cardiology

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Variation in diagnostic testing for older patients with syncope in the Emergency Department

The American Journal of Emergency Medicine

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Subarachnoid Hemorrhage, or Is It?

Publication date: Available online 23 July 2018

Source: The Journal of Emergency Medicine

Author(s): Utsha G. Khatri, Edward T. Dickinson

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Recurrent Diffuse Large B-Cell Lymphoma Presenting with Pancoast Syndrome: A Rare Cause of Radicular Neck Pain in the Emergency Department

Publication date: Available online 23 July 2018

Source: The Journal of Emergency Medicine

Author(s): Matthew S. Correia, Richard F. Clark

Abstract

Background

Pancoast syndrome is an uncommon complication of apical lung tumors. Symptoms include pain, brachial plexopathy, and Horner's syndrome, and are the result of extrinsic compression of tissues within the thoracic inlet. Lymphoma is a very rare etiology.

Case Report

We describe the presentation of a 59-year-old male with recurrent diffuse large B-cell lymphoma presenting with Pancoast syndrome.

Why Should an Emergency Physician Be Aware of This?

Cancer is an uncommon cause of radicular neck pain but should be considered in the differential, particularly when constitutional complaints are also present. Symptoms and physical examination findings associated with Pancoast syndrome are the consequence of compression of the C7–T2 vertebral roots and sympathetic chain. Computed tomography is usually required to definitively visualize the mass.

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Prognostic Value of sLOX-1 Level in Acute Coronary Syndromes Based on Thrombolysis in Myocardial Infarction Risk Score and Clinical Outcome

Publication date: Available online 23 July 2018

Source: The Journal of Emergency Medicine

Author(s): Sina Mashayekhi, Mojtaba Ziaee, Alireza Garjani, Parvin Sarbakhsh, Samad Ghaffari

Abstract

Background

Biomarkers possess important diagnostic and prognostic value in acute coronary syndromes (ACSs). Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) is one of the markers involved in atherosclerotic plaque vulnerability and rupture.

Objective

This study aimed to evaluate the prognostic value of sLOX-1 through its correlation with Thrombolysis in Myocardial Infarction (TIMI) risk score and its possible association with clinical outcomes in 2 major spectrums of ACS.

Methods

A prospective cross-sectional study was planned, and 320 patients who underwent diagnostic coronary angiography were selected (in first 24 h after coronary angiography): those with documented ST elevation myocardial infarction or unstable angina/non-ST elevation myocardial infarction. sLOX-1 was measured immediately after administration in the emergency department. The TIMI risk score was calculated separately for both groups. In hospital death, heart failure and recurrent infarction were considered major adverse cardiac events.

Results

There was a significant positive correlation between sLOX-1, TIMI risk score, major adverse cardiac events, and heart failure. The optimal cutoff value of sLOX-1 to predict clinical endpoints was 1.75 ng/mL in patients with ST elevation myocardial infarction and 1.35 ng/mL in patients with unstable angina/non-ST elevation myocardial infarction.

Conclusions

Circulating sLOX-1 could be used as a biomarker to predict major adverse cardiac events in patients with ACS and may be clinically useful in the triage and management of these patients.

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