Airway has been paramount to the management of cardiac arrest since the earliest endeavors in resuscitation. The use of tobacco smoke enemas to resuscitate drowning victims on the banks of the Thames was documented as far back as 17461. Such efforts while anatomically misplaced, were in principle well intended. Although, we have since discovered alternative […]
EMCrit Project by Rory Spiegel.
Airway has been paramount to the management of cardiac arrest since the earliest endeavors in resuscitation. The use of tobacco smoke enemas to resuscitate drowning victims on the banks of the Thames was documented as far back as 17461. Such efforts while anatomically misplaced, were in principle well intended. Although, we have since discovered alternative […]
EMCrit Project by Rory Spiegel.
Cyanide, Hydrogen Sulfide, Detergent Suicide, and Military Teletoxicology with Dr. Vik Bebarta Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Vik Bebarta and learn about cyanide infused bacon, hydrogen sulfide, detergent suicide, military teletoxicology and the variety of antidotes and therapies to make you well. Chock full of smoky goodness, this is a […]
EMCrit Project by Tox & Hound.
Cyanide, Hydrogen Sulfide, Detergent Suicide, and Military Teletoxicology with Dr. Vik Bebarta Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Vik Bebarta and learn about cyanide infused bacon, hydrogen sulfide, detergent suicide, military teletoxicology and the variety of antidotes and therapies to make you well. Chock full of smoky goodness, this is a […]
EMCrit Project by Tox & Hound.
Publication date: Available online 31 August 2018
Source: The Journal of Emergency Medicine
Author(s): William Berrigan, Roderick Geer, James S. Jelnick, Jonathan E. Davis, Robert Bunning
Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.
We set out to review cervical spine injuries in children and advise on current best practice with regards to management.
Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.
Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.
To define risk factors for rehospitalization following fragility hip fractures and to create a predictive model.
A retrospective cohort study of patients 65 years and older, who were treated operatively following fragility hip fractures between 01.2011 and 06.2016. Patients were allocated into two study groups based on the occurrence of recurrent hospitalizations in the year following surgery. Demographic information, comorbidities, and in-hospital characteristics were collected, as was information regarding 1-year readmissions. Multivariate analysis of factors predictive of rehospitalizations was performed, followed by a logistic regression using all predictors with p < 0.05. A stepwise backwards elimination method was used to create the predictive model.
Eight hundred and fifty-one patients were included; 369 (43.4%) had recurrent hospitalizations within the first post-operative year. Patients who were rehospitalized were more likely to be males, to use a walking aid and to live dependently. They had a higher age-adjusted Charlson’s comorbidity index (ACCI) score, a higher perveance of atrial fibrillation, lower hemoglobin, worse renal function, less platelets, and longer time to surgery. Prevalence of in-hospital complications was similar. Six variables were found to independently influence the chance for readmissions: male gender, the use of a walking aid, higher ACCI score, lower hemoglobin, atrial fibrillation, and a longer surgical delay. Only the first four were found to be adequate predictors and were added to the prediction formula.
High 1-year readmission rates are seen following discharge in patients with fragility hip fractures. Addressing risk factors might aid to better rehabilitate patients and reduce morbidity.
The purpose of this study was to evaluate the effectiveness between percutaneous and open pedicle screw fixation without fusion for treating type A3 and A4 thoracolumbar fractures. Traumatic thoracolumbar burst fracture is a common pathology without a consensus on the best treatment approach. Percutaneous pedicle screw fixation (PPSF) systems have been recently introduced in the treatment of spinal fractures to reduce the adverse effects associated with the conventional open approaches, such as iatrogenic muscle denervation and pain.
A prospective analysis was made to evaluate consecutive 46 patients with type A3 and A4 thoracolumbar fractures. Patients were divided into a percutaneous pedicle screw fixation group (PPSF) and an open pedicle screw fixation group (OPSF). The mean age of patients in PPSF group (12 men, 11 woman) was 49.9 years and in OPSF group (10 men, 13 women) 52.2 years. For the purpose of evaluation, the radiological assessment of the bisegmental Cobb angle, the loss of correction, the volume of blood loss, operation time, cumulative radiation time and dose were recorded and compared.
All patients were followed up for 12 months. There were no significant differences between OPSF and PPSF in the Cobb angle preoperative and postoperative angle and the loss of bisegmental correction. In PPSF group, the mean preoperative Cobb angle was 10.9° and improved by 4.5° postoperatively, and in OPSF group the preoperative angle was 12.1° and postoperatively improved by 3.8°. Significant differences between OPSF and PPSF were found in the mean cumulative radiation time, radiation dose and operation time. PPSF group also had a significantly lower perioperative blood loss.
Both open and percutaneous short-segment pedicle fixation were safe and effective methods to treat thoracolumbar burst fractures. Percutaneous fixation without fusion seems to be suitable for type A3 and A4 fractures.
The purpose of this study is to characterize the distal anatomic end-point of a tibial intramedullary nail placed using modern surgical techniques. The goal is to improve reduction of distal tibia fractures.
An intramedullary nail was placed in 14 skeletally mature legs. This included 8 patients with mid-shaft tibial fractures and 6 intact cadaveric legs. Each nail was a titanium cannulated tibial nail, size 10- or 11-mm. The nails were placed using a suprapatellar or transpatellar approach with an ideal starting point. All legs received post-nail insertion CT scans and fluoroscopy. The main outcome measure was the terminal location of the nail just proximal to the distal tibial physeal scar, as seen on axial CT and fluoroscopic views of the ankle (mortise and lateral). The end-point was measured as the (1) ratio of medial–lateral tibial width (ML ratio) and (2) ratio of anterior–posterior tibial width (AP ratio). Two-tailed Welch’s t tests were used to compare the actual, observed position of the nail to the hypothesized center–center position (H0 = ML and AP ratio of 0.5).
All enrolled patients (n = 8) and cadaveric legs were included (n = 6). On axial CT, the average distance from the medial tibial cortex to the nail center as a ratio of medial–lateral tibial width was 0.63, 95% CI 0.60–0.67, p < 0.001 (Patient = 0.60, 95% CI 0.55–0.64, p = 0.001) (Cadaver = 0.68, 95% CI 0.64–0.73, p < 0.001). On fluoroscopic mortise views, the distance from the medial cortex to the nail center as ratio of medial–lateral tibial width was 0.64, 95% CI 0.60–0.67, p < 0.001 (Patient = 0.61, 95% CI 0.56–0.65, p < 0.001) (Cadaver = 0.67, 95% CI 0.63–0.72, p < 0.001). The AP ratio was not significantly different from 0.5 on either axial CT or fluoroscopic mortise views (p > 0.05).
The distal end-point of a tibial intramedullary nail is lateral (ML plane) and center (AP plane) in both cadaveric legs and patients with midshaft tibia fractures. These results suggest that the treatment of distal tibia fractures with intramedullary nails may be improved by positioning the nail slightly lateral in the distal segment.
Diagnostic level I.
To assess the general knowledge and practices related to burn first aid treatment (BFAT) and to examine age, gender, socioeconomic status, education and previous history of exposure to burn (self/family member) as factors influencing burn first aid knowledge among the general population of Rawalpindi.
A cross-sectional, descriptive survey.
Three major tertiary care hospitals of Rawalpindi, from August 2017 to May 2018.
All consenting people ≥ 18 years of age, with or without a prior history of burn, accompanying patients to three major tertiary care centers of Rawalpindi were administered a pre-tested structured questionnaire. The questionnaire was divided into two sections; socio-demographic section and knowledge on BFAT. Those who were illiterate and could not fill the questionnaire were interviewed and their responses were marked by the researchers themselves. Data were analyzed using SPSS version 21.
A total of 400 participants comprising 205 (51.3%) males and 195 (48.8%) females with a mean age of 38 ± 10.3 years were included. The majority (58%) were educated up to 12th grade or higher. “Toothpaste” (47.5%) followed by “cool running water” (20.3%) were the two most frequently applied items following a burn injury. Only 8.8% respondents applied cold water for the ideal time duration. Overall, 83% of the participants provided correct answers for 25–50% of the survey questions. Socioeconomic and educational status of the participants had a significant association with burn first aid knowledge.
A significant limitation of knowledge regarding BFAT was seen among the general population of Rawalpindi.
Health-related quality of life (HRQOL) is increasingly recognized as a benchmark in trauma outcome research, with few studies having evaluated the HRQOL in trauma patients. The aim of our study was to assess the change in trauma patients’ HRQOL at 12 months post-injury and to describe their living situation and return to work status.
A prospective cohort study was performed at a Japanese tertiary care hospital from September 2013 to September 2015. The short-form (SF-36) health survey was used at discharge, and 6 and 12 months post-injury. We obtained information regarding living situation at 12 months post-injury.
Complete data were collected from 129 patients. The median age and injury severity score were 66 years 17, respectively. The physical and role-social component scores improved significantly between hospital discharge and 6 months post-injury. However, the mental component score decreased significantly during this period. There was no significant increase in any of the 3 SF-36 component scores between 6 and 12 months post-injury. At 12 months post-injury, 106 (82%) patients were independent and 15 (12%) patients were dependent on home care services. The return to work rate was 65% (47/72).
Our study suggests that the quality-of-life of Japanese trauma patients generally improved over time, but remained lower than the Japanese national average. Most trauma patients return to home and work within 12 months post-injury.
Myeloid dendritic cells (MDC) decline significantly after multiple traumas which might be due to an increased migration into injured regions. Ubiquitin is released from dying cells and is increased in serum after trauma. Ubiquitin can bind to the chemokine receptor CXCR4. Thus, we hypothesized that elevated ubiquitin provides a chemotactic signal for MDC to injured regions.
Surgical wound fluid (SWF) and serum from patients with mono-trauma (n = 20) were used to simulate the humoral situation in injured tissue. MDC were identified by flow cytometry. Chemotaxis was measured using transwell migration assays. Ubiquitin and CXCL12 (natural CXCR4 ligand) were determined by ELISA.
MDC express CXCR4 and fluorescence-labeled ubiquitin binds to MDC. Ubiquitin exerts a dose-dependent chemotactic effect (fourfold at 100 ng/mL, p < 0.05). Ubiquitin concentration was sixfold higher in SWF (p < 0.05), whereas CXCL12 was increased in serum. MDC migration towards SWF was significantly reduced (− 40%, p < 0.05), if ubiquitin was neutralized by specific antibodies.
Ubiquitin is increased in SWF and exerts a significant chemotactic effect on MDC. This mechanism might play a role in attraction of immune cells to injured regions and might contribute to the decline of circulating MDC in multiple traumas.
The local circulatory changes induced by intramedullary reaming are not fully understood. This study aimed to analyse the short-term local microcirculation associated with different surgical strategies in a porcine model with a mid-shaft fracture.
German landrace pigs were subjected to a standardised femoral fracture under standard anaesthesia and intensive care monitoring. One group was subjected to intramedullary reaming and nailing (nail group), while a second group was stabilised with external fixation (fix ex group). Microcirculation [e.g. relative blood flow (flow), oxygen saturation and relative haemoglobin concentration] was measured in the vastus lateralis muscle adjacent to the fracture using an O2C (oxygen to see, LEA Medizintechnik GMBH) device at 0 (before fracture, baseline), 6 (90-min posttreatment), 24, 48 and 72 h.
A total of 24 male pigs were used (nail group, n = 12; fix ex group, n = 12). During the observation period, a significant increase of flow was found at 6 (P = 0.048), 48 (P = 0.023) and 72 h (P = 0.042) in comparison with baseline levels. Local oxygen delivery was significantly higher at 48 (P = 0.017) and 72 h (P = 0.021) in animals in the nail group compared to animals in the external fixation group.
This study used a standardised porcine femoral fracture model and determined a significant increase in local blood microcirculation (e.g. flow and oxygen delivery) in animals treated with intramedullary reaming compared to external fixation. These changes may be of importance for fracture healing and local and systemic inflammatory responses. Further studies in this area are justified.
Publication date: Available online 28 August 2018
Source: The Journal of Emergency Medicine
Author(s): Ashley McCaskill, Chandler Finney Inabinet, Kristl Tomlin, Judith Burgis
Prepubertal genital bleeding can be caused by a variety of etiologies including trauma, infection, structural, hematologic disorders, precocious puberty, and malignancy. Urethral prolapse can be seen in prepubescent girls due to a relative estrogen deficiency. Urethral prolapse classically presents with urethral mass and vaginal bleeding, often associated with constipation.
A healthy 6-year-old White girl presented to the Pediatric Emergency Department (ED) with vaginal bleeding for 1 day preceded by a few months of constipation. In the ED the patient's physical examination was remarkable for a tender, nonmobile mass at the vaginal introitus. Transabdominal pelvic and renal ultrasounds were unremarkable. The emergency physician's working diagnosis was a vaginal mass concerning for sarcoma botryoides. Pediatric and Adolescent Gynecology (PAG) was consulted. They performed an examination under anesthesia (EUA) with cystoscopy and vaginoscopy. The EUA confirmed a urethral prolapse approximately 2 cm in diameter. The patient was treated with conjugated estrogen vaginal cream. At her 1-month follow-up, the urethral prolapse had resolved.
Performing a proper pelvic examination of a prepubescent girl presenting with vulvovaginal bleeding is crucial to form an accurate diagnosis in the ED setting. By placing the young girl in the frog-leg or knee-chest position and using both lateral and downward traction of the vulva, one can adequately visualize the external genitalia and outer 1/3 of the vagina. This can help streamline diagnosis and avoid unnecessary examinations and anxiety.
Publication date: Available online 28 August 2018
Source: The Journal of Emergency Medicine
Author(s): Samuel H.F. Lam, Adam Sivitz, Kiyetta Alade, Stephanie J. Doniger, Mark O. Tessaro, Joni E. Rabiner, Alexander Arroyo, Edward M. Castillo, Caroline A. Thompson, Mingan Yang, Rakesh D. Mistry
Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches.
To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting.
Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7–10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians.
In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty.
Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.
Publication date: Available online 28 August 2018
Source: The Journal of Emergency Medicine
Author(s): Scott A. Simpson, Chelsie Monroe
Psychiatric presentations are common in emergency departments (EDs), but the standard of care for treatment remains poorly defined. We introduced standards for emergency psychiatric evaluations that included obtaining collateral information, writing a safety plan for discharging patients, identifying the next best provider, and alerting that provider to the patient's visit.
We sought to demonstrate the feasibility and clinical impact of implementing standards for emergency psychiatric evaluations.
To evaluate feasibility, physicians attested to completion in the electronic health record. To evaluate the effect on clinical outcomes, we compared admission rates, 30-day return rates, and median length of stay from a 4-month pre-implementation period to a 4-month post-implementation period. Data were extracted from a quality-improvement database.
There were 1896 patient encounters in the pre-implementation period and 1937 encounters post-implementation. Pre-and post-cohorts were similar demographically. Collateral was obtained for 1035 (86%) encounters, a written safety plan was completed for 793 (77%) eligible patients, the next-best provider was identified for 1094 (91%), and that provider was contacted for 837 (70%). There was no difference from pre to post periods in admission rates (17% vs. 18%; p = 0.36), median length of stay (13.3 ± 0.6 vs. 12.5 ± 1.4; p = 0.35), or 30-day return rates (15% vs. 16%; p = 0.66).
This standard work for emergency psychiatric evaluations was feasible even in a highly acute patient population. However, the benefits of this intervention are less clear. We question the utility of prevailing metrics in emergency psychiatry.
Publication date: Available online 28 August 2018
Source: The Journal of Emergency Medicine
Author(s): Nicola Malagutti, Andrea Di Laora, Carlo Barbetta, Elisabetta Groppo, Valeria Tugnoli, Elisabetta Sette, Luigi Astolfi, William Beswick, Michela Borin, Andrea Ciorba, Stefano Pelucchi, Francesco Stomeo, Marco Contoli
Dyspnea secondary to acute upper airways airflow limitation (UAAFL) represents a clinical emergency that can be difficult to recognize without a suitable history; even when etiology is known, parameters to assess the severity are unclear and often improperly used.
The aim of this study was to assess the role of peripheral oxygen saturation (SpO2) as a predictor of severity of upper airway obstruction.
The authors propose an experimental model of upper airway obstruction by a progressive increase of UAAFL. Ten healthy volunteers randomly underwent ventilation for 6 min with different degrees of UAAFL. SpO2, heart rate, respiratory rate (RR), tidal volume, accessory respiratory muscle activation, and subjective dyspnea indexes were measured.
In this model, SpO2 was not reliable as the untimely gravity index of UAAFL. Respiratory rate, visual analogue scale (VAS), and Borg dyspnea scale were statistically correlated with UAAFL (p < 0.0001 for RR and p < 0.05 for VAS and Borg scale). No significant changes were observed on heart rate (p > 0.05) and tidal volume (p > 0.05); a RR ≤ 7 breaths/min; VAS and Borg scale showed statistically significant parameters changes (p < 0.05).
RR, VAS, and Borg dyspnea scales are sensitive parameters to detect and stage, easily and quickly, the gravity of an upper airways impairment, and should be used in emergency settings for an early diagnosis of a UAAFL. SpO2 is a poorer predictor of the degree of upper airways flow limitation.
Background Ambulance transfer is the first contact with the healthcare system for many patients in emergency conditions. We aimed to identify prognostic risk factors accessible in the prehospital phase that indicate an increased risk of 7-day mortality. Patients and methods We included patients aged 18 years or older, transferred by ambulance to the emergency department at Odense University Hospital, from 1 April 2012 to 30 September 2014. We carried out multivariate logistic regressions, adjusted for age and sex, to describe the relationship between vital sign values recorded in the prehospital setting and 7-day mortality. Results A total of 32 076 ambulance transfers were recorded. Of these, 20 328 were first-time transfers, including 2692 that received assistance from a physician-staffed mobile emergency care unit (MECU). The 7-day mortality was 5.3% [95% confidence interval (CI): 5.0–5.6]. The risk of death increased with age. The odds ratios (ORs) were 2.0 (95% CI: 1.1–3.5) for ages 30–44 years and 7.3 (95% CI: 4.5–11) for ages 45–69 years compared with the 18–29-year-olds. All abnormal vital sign values were associated with increased 7-day mortality. Glasgow Coma Score of less than 14 had the strongest association (OR: 17, 95% CI: 14.7–19.7). MECU assistance showed an adjusted OR of 5.3 (95% CI: 4.6–6.1). Conclusion The overall 7-day mortality was 5.3%, but differed in the two subgroups, with 15.4% in the MECU-assisted ambulance transfers and 3.8% in non-MECU-assisted transfers. Older age and Glasgow Coma Scores below 14 were the strongest of factors associated significantly with 7-day mortality.
Background Advanced airway management of combat casualties during scene-to-hospital air transport is challenging. Because of the short transport time, flight physicians of the Israeli military airborne combat evacuation unit are approved for the use of a laryngeal mask airway (LMA) in the event of failed endotracheal intubation (ETI). The aim of this study was to assess the effectiveness of LMA use during scene-to-hospital transport of combat casualties in Israel. Patients and methods A retrospective cohort analysis of all combat casualties treated with ETI during scene-to-hospital transport over a 3-year period was carried out. Successful LMA insertion was defined as satisfactory placement of the device on the basis of adequate chest expansion with bag-mask ventilation. Results The median flight time from scene to hospital was 13 min [interquartile range (IQR): 9–15 min]. Sixty-five casualties underwent ETI attempts, 47 successful and 18 failed. All 18 casualties who had failed ETI underwent LMA insertion as a rescue treatment. Six casualties suffered from traumatic brain injury, six had firearm injuries, two had blast injuries, and two had inhalational injuries. LMA insertion was successful in 16/18 (88.9%) casualties, 14 survived to hospital discharge, whereas two were declared dead upon hospital arrival. Two cases of LMA insertion were unsuccessful, but patients survived to hospital discharge. Among the 16 successful cases, the median oxygen saturation on scene-pickup before LMA insertion and on hospital-handover with LMA in place were 90% (IQR: 84–96%) and 98% (IQR: 96–99%), respectively (P
Violence has been declining in the UK for two decades, with most assaults being alcohol related. The Licensing Act 2003 (England and Wales) aimed to reduce alcohol-related crime, giving local authorities control over premises licensing. We performed a systematic review of original research with the primary outcome of change in violence rates since the Act’s implementation, including hospital-defined and police-defined measures of violence. Our secondary outcome was temporal distribution of violence. Fifteen studies were included, which were of overall poor quality. Seven found reduced violence rates after the Act’s implementation, three found increased rates and five found no significant change. A subset of nine studies analysed temporal distribution, eight finding displacement of incidents later. This is the most complete analysis to date of the effect of this Act on violence, finding a lack of reliable evidence to answer the research question, but little to suggest that the Act has markedly impacted already-declining violence rates.
Background Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. The effects of epidemiological changes such as ageing of the population and increased traffic safety on the incidence of TBI are unknown. Objective The objective of this study was to evaluate trends in TBI-related emergency department (ED) visits, hospitalization and mortality in the Netherlands between 1998 and 2012. Design This was a retrospective observational, longitudinal study. Main outcome measures The main outcome measures were TBI-related ED visits, hospitalization and mortality. Results Between 1998 and 2012, there were 500 000 TBI-related ED visits in the Netherlands. In the same period, there were 222 000 TBI-related admissions and 17 000 TBI-related deaths. During this period, there was a 75% increase in ED visits for TBI and a 95% increase for TBI-related hospitalization; overall mortality because of TBI did not change significantly. Despite the overall increase in TBI-related ED visits, this increase was not evenly distributed among age groups or trauma mechanisms. In patients younger than 65 years, a declining trend in ED visits for TBI caused by road traffic accidents was observed. Among patients 65 years or older, ED visits for TBI caused by a fall increased markedly. TBI-related mortality shifted from mainly young (67%) and middle-aged individuals (
Community-acquired pneumonia (CAP) is one of the most widespread and severe infectious diseases worldwide. In the emergency department (ED), there is still a need for a rapid and accurate tool that can diagnose CAP. Lung ultrasound (LUS) is a recent tool that is increasingly being for this purpose. So far, the LUS has been evaluated on a wide range of patients, but not yet on the specific population in the ED through a meta-analysis. Our aim was to assess the accuracy of the LUS in diagnosing CAP in this setting through a systematic review and a meta-analysis. A systematic research of literature was carried out for all published studies comparing the diagnostic accuracy of the LUS against chest radiography or computerized tomography scan in patients older than 18 years of age with clinical criteria for CAP assessed in the ED. We extracted the descriptive and quantitative data from eligible studies, and calculated the pooled sensitivity, specificity, and diagnostic odds ratio. We defined the summary receiver operating characteristic curve. Our initial search strategy yielded 10 377 studies, of which 17 (0.2%) were eligible. These studies provided a combined sample size of 5108 participants. The general risk of bias of the considered studies was quite low, but some concerns were highlighted. The diagnostic odds ratio was around 181 (I2: 27%). The pooled area under the curve, sensitivity, and specificity were, respectively, 97, 92, and 93%. The LUS was found to be an accurate tool in diagnosing CAP in adult patients in the ED. More methodologically rigorous trials are needed.
Objective The aim of this study was to evaluate a novel pericardiocentesis technique using an in-plane parasternal medial-to-lateral approach with the use of a high-frequency probe in patients with cardiac tamponade. Background Echocardiography is pivotal in the diagnosis of pericardial effusion and tamponade physiology. Ultrasound guidance for pericardiocentesis is currently considered the standard of care. Several approaches have been described recently, which differ mainly on the site of puncture (subxiphoid, apical, or parasternal). Although they share the use of low-frequency probes, there is absence of complete control of needle trajectory and real-time needle visualization. An in-plane and real-time technique has only been described anecdotally. Methods and results A retrospective analysis of 11 patients (63% men, mean age: 37.7±21.2 years) presenting with cardiac tamponade admitted to the tertiary-care emergency department and treated with parasternal medial-to-lateral in-plane pericardiocentesis was carried out. The underlying causes of cardiac tamponade were different among the population. All the pericardiocentesis were successfully performed in the emergency department, without complications, relieving the hemodynamic instability. The mean time taken to perform the eight-step procedure was 309±76.4 s, with no procedure-related complications. Conclusion The parasternal medial-to-lateral in-plane pericardiocentesis is a new technique theoretically free of complications and it enables real-time monitoring of needle trajectory. For the first time, a pericardiocentesis approach with a medial-to-lateral needle trajectory and real-time, in-plane, needle visualization was performed in a tamponade patient population.
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable alternative to resuscitative thoracotomy (RT) in refractory hemorrhagic patients. We evaluated REBOA strategies using Japanese multi-institutional data. Patients and methods The DIRECT-IABO investigators registered trauma patients requiring REBOA from 18 hospitals. Patients’ characteristics, outcomes, and time in initial treatment were collected and analyzed. Results From August 2011 to December 2015, 106 trauma patients were analyzed. The majority of patients were men (67%) (median BMI of 22 kg/m2, 96% blunt injured). REBOA occurred in the field (1.9%, all survived >30 days), emergency department (75%), angiography suite (17%), and operating room (1.9%). Initial deployment was at zone I in 93% and partial occlusion in 70% of cases. RT and REBOA were combined in 30 patients (RT+REBOA group) who showed significantly higher injury severity score (44 vs. 36, P=0.001) and chest abbreviated injury scale (4 vs. 3; P
Objective The aim of this study was to compare the stratification of sepsis patients in the emergency department (ED) for ICU admission and mortality using the Predisposition, Infection, Response and Organ dysfunction (PIRO) and quick Sequential Organ Failure Assessment (qSOFA) scores with clinical judgement assessed by the ED staff. Patients and methods This was a prospective observational study in the ED of a tertiary care teaching hospital. Adult nontrauma patients with suspected infection and at least two Systemic Inflammatory Response Syndrome criteria were included. The primary outcome was direct ED to ICU admission. The secondary outcomes were in-hospital, 28-day and 6-month mortality, indirect ICU admission and length of stay. Clinical judgement was recorded using the Clinical Impression Scores (CIS), appraised by a nurse and the attending physician. The PIRO and qSOFA scores were calculated from medical records. Results We included 193 patients: 103 presented with sepsis, 81 with severe sepsis and nine with septic shock. Fifteen patients required direct ICU admission. The CIS scores of nurse [area under the curve (AUC)=0.896] and the attending physician (AUC=0.861), in conjunction with PIRO (AUC=0.876) and qSOFA scores (AUC=0.849), predicted direct ICU admission. The CIS scores did not predict any of the mortality endpoints. The PIRO score predicted in-hospital (AUC=0.764), 28-day (AUC=0.784) and 6-month mortality (AUC=0.695). The qSOFA score also predicted in-hospital (AUC=0.823), 28-day (AUC=0.848) and 6-month mortality (AUC=0.620). Conclusion Clinical judgement is a fast and reliable method to stratify between ICU and general ward admission in ED patients with sepsis. The PIRO and qSOFA scores do not add value to this stratification, but perform better on the prediction of mortality. In sepsis patients, therefore, the principle of ‘treat first what kills first’ can be supplemented with ‘judge first and calculate later’.
No abstract available
Introduction Emergency Medical Communication Centre (EMCC) represents a pivotal link in the chain of survival for those requiring rapid response for out-of-hospital medical emergencies. Assessing and grading the performance of EMCCs are warranted as it can affect the health and safety of the served population. Objective The aim of our work was to describe the activity on an EMCC and to explore the associations between different key performance indicators. Methods We carried out our prospective observational study in the EMCC of Nantes, France, from 6 June 2011 to 6 June 2015. The EMCC performance was assessed with the following key performance indicators: answered calls, Quality of Service 20 s (QS20), occupation rate and average call duration. Results A total of 35 073 h of dispatch activity were analysed. 1 488 998 emergency calls were answered. The emergency call incidence varied slightly from 274 to 284 calls/1000 citizens/year between 2011 and 2015. The median occupation rate was 35% (25–44). QS20 was correlated negatively with the occupation rate (Spearman’s ρ: −0.78). The structural equation model confirmed that the occupation rate was highly correlated with the QS20 (standardized coefficient: −0.89). For an occupation rate of 26%, the target value estimated by our polynomial model, the probability of achieving a QS20 superior or equal to 95% varied between 56 and 84%. Conclusion The occupation rate appeared to be the most important factor contributing towards the QS20. Our data will be useful to develop best practices and guidelines in the field of emergency medicine communication centres.
Objectives The two-finger technique (TFT) using the index-middle fingers of the right hand (TFT-R23) was recently confirmed to produce deeper chest compression depth (CCD) compared with the TFT using any other fingers. This study was carried out to confirm whether the TFT-R23 would be as effective as the two-thumb technique (TTT). In addition, individual finger strengths were measured to identify the reasons why the TTT and TFT-R23 produced deeper CCD than any other methods. Methods This prospective randomized cross-over trial compared TTT with TFT-R23. A total of 37 doctors conducted 2 min single-rescuer cardiopulmonary resuscitation using TTT and TFT-R23 in a random order using a 3-month-old sized infant manikin laid on the floor. The chest compression to ventilation ratio was set to 15 : 2. In addition, finger strengths were measured using a pinch meter. Results The actual CCD of the TTT was significantly deeper than that of the TFT-R23 (41.3±1.3 vs. 39.8±1.5 mm, P
by Sarah Shafer You’re taking care of a 4-year-old who got into some medication. His pupils are small, his heart rate is slow, and he’s more drowsy than a resident at a late night party. Toxidrome fluent, you give him a slug of naloxone . . . and . . . nothing happens. […]
EMCrit Project by Tox & Hound.
by Sarah Shafer You’re taking care of a 4-year-old who got into some medication. His pupils are small, his heart rate is slow, and he’s more drowsy than a resident at a late night party. Toxidrome fluent, you give him a slug of naloxone . . . and . . . nothing happens. […]
EMCrit Project by Tox & Hound.
Publication date: Available online 27 August 2018
Source: The Journal of Emergency Medicine
Author(s): Brian Ferguson, Justin Geralds, Jessica Petrey, Martin Huecker
Malpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization.
This review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk.
The environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced.
There are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.
Publication date: Available online 27 August 2018
Source: The Journal of Emergency Medicine
Author(s): Kevin Ting, Venkatachalam Mulukutla, Wayne J. Franklin, Wilson W. Lam
Anomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia.
We describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%).
ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization.
CTP for posterior stroke?
EMCrit Project by Ashley Mogul.
CTP for posterior stroke?
EMCrit Project by Ashley Mogul.
Meta-analyses are widely assumed to be robust, without any attempt to test their fragility. This post describes two techniques to evaluate the fragility of a meta-analysis
EMCrit Project by Josh Farkas.
Meta-analyses are widely assumed to be robust, without any attempt to test their fragility. This post describes two techniques to evaluate the fragility of a meta-analysis
EMCrit Project by Josh Farkas.
How to use the cric models and optimal surgical airway technique.
EMCrit Project by Scott Weingart.
How to use the cric models and optimal surgical airway technique.
EMCrit Project by Scott Weingart.
Publication date: Available online 24 August 2018
Source: The Journal of Emergency Medicine
Author(s): Michael S. Pulia, Rebecca J. Schwei, Brian W. Patterson, Michael D. Repplinger, Maureen A. Smith, Manish N. Shah
The optimal approach to outpatient antibiotic use after surgical drainage of abscesses is unclear given conflicting clinical trial results.
Our primary objective was to evaluate the real-world effectiveness of outpatient antibiotic prescribing after surgical drainage of cutaneous abscesses on reducing treatment failure.
We performed a retrospective observational study using data extracted from the electronic health record of a single academic health care system. All emergency department (ED) visits that resulted in discharge with a surgical drainage of a cutaneous abscess procedure code were included in the sample. All visits were categorized into having received or not having received an antibiotic prescription at the index visit. Outcome frequencies were compared using Pearson's chi-squared test. A multivariable logistic regression model was used to estimate the odds of treatment failure among those who did and did not receive an antibiotic prescription at their index ED visit.
The final sample consisted of 421 index ED visits, of which 303 (72%) received an antibiotic prescription. Treatment with antibiotics after drainage did not significantly reduce the odds of composite treatment failure within 30 days when controlling for sociodemographic and clinical encounter variables (odds ratio 0.52, 95% confidence interval 0.23–1.21).
This real-world, comparative effectiveness analysis did not demonstrate any significant reduction in treatment failure with the use of antibiotics after drainage of abscesses in the ED. It is unclear if the clinical benefit observed under controlled trial conditions will carry over to routine clinical practice where varied antibiotic regimens are the norm and local bacterial resistance patterns vary.
Publication date: Available online 24 August 2018
Source: The Journal of Emergency Medicine
Author(s): Kun-Yu Lee, Hao-Chien Chao, Sai-Wai Ho
Publication date: Available online 24 August 2018
Source: The Journal of Emergency Medicine
Author(s): Akanksha Agrawal, Mohammad Nour Zabad, Sandeep Dayanand, Georgios Lygouris, Christian Witzke
Acute pericardial pathologies, such as pericardial effusion, pericarditis, and cardiac tamponade, have been reported rarely in patients presenting as ST-elevation myocardial infarction (STEMI). We present a series of 3 patients with STEMI, where an undiagnosed pericardial effusion led to pericardial tamponade and subsequent cardiocirculatory collapse.
This is a case series of 3 patients, all women, aged 72, 64, and 54 years who presented to the emergency department with chest pain or syncope and were found to have STEMI with hemodynamic instability. They were taken to the catheterization laboratory for urgent coronary revascularization requiring mechanical circulatory support (intra-aortic balloon pump or impella). During catheterization, all 3 patients were diagnosed with large pericardial effusion using hemodynamic parameters and bedside transesophageal echocardiogram. Commonly ignored, pericardial tamponade and acute large pericardial effusion can be the cause of cardiocirculatory collapse. Two of the 3 patients survived with aggressive interventions requiring pericardial drains, long-term mechanical circulatory support, and effective postoperative rehabilitation.
It is important for treating clinicians, including emergency physicians, intensivist, and cardiologist, to consider the differential of a cardiac tamponade due to a pericardial effusion as a potential cause for hypotension in patients with an acute STEMI.
Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length.
We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck–shaft angle, tip–apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant.
The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05).
We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes.
Level IV, Retrospective case series study.
Publication date: Available online 22 August 2018
Source: The Journal of Emergency Medicine
Author(s): Lisa D. Mills
Publication date: Available online 22 August 2018
Source: The Journal of Emergency Medicine
Author(s): Ian S. deSouza, Roshanak Benabbas
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s):
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Lamya Mubayed, Brie-Ann A. Muller, Jessica L. Jacobson, Howard A. Hast, Hoang H. Nguyen
Colchicine ingestion is rare but highly lethal. Patients usually die of multiorgan failure and cardiogenic shock. Colchicine is not only associated with depressed myocardial function but also with fatal heart rhythm disturbances, such as complete heart block, ventricular tachycardia, and asystole. While histologic changes of myocytes are well known, the mechanism by which colchicine affects cardiac impulse generation and conduction is not fully understood.
We present a case of colchicine ingestion with sinus bradycardia, marked sinus arrhythmia, and first- and second-degree heart block. A 10-year-old previously healthy boy was brought to the emergency department for the sudden onset of dizziness, abdominal pain, and vomiting after ingesting his grandfather's colchicine and furosemide. His symptoms improved with ondansetron and intravenous normal saline. However, because of the colchicine ingestion, he was admitted to the pediatric intensive care unit for observation. He first developed PR prolongation (∼4–30 h postingestion) followed by marked sinus bradycardia and sinus arrhythmia along with second-degree heart block (∼48–60 hours postingestion). The minimum heart rate was 40 beats/min. Marked sinus arrhythmia was observed, suggesting an increase in parasympathetic activity. His heart rhythm improved initially with less sinus arrhythmia followed by resolution of heart block. He was discharged home without any sequelae. Holter monitoring 1 week after discharge showed normal heart rate variability for age.
This case provides novel insights into how colchicine may affect the heart's electrophysiology. Colchicine may increase the parasympathetic tone enough to cause sinus bradycardia and different degrees of heart block.
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Arian Anderson
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Arian Anderson
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Arian Anderson
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Sarah Markus
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Sarah Markus
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Sarah Markus
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Elizabeth Nichole Malik
Publication date: September 2018
Source: The Journal of Emergency Medicine, Volume 55, Issue 3
Author(s): Elizabeth Nichole Malik
