Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Abstract

Purpose

The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.

Methods

MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy.

Results

Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I² = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies.

Conclusions

Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

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EM Nerd-An Addendum to the Case of the Non-inferior Inferiority

Until recently the management of acute appendicitis has lay squarely in the hands of the surgeon. But there is a growing body of evidence examining the use of antibiotics alone in uncomplicated appendicitis. Most of the data exploring this question has found that the majority of patients treated with antibiotics alone will avoid surgery in […]

EMCrit Project by Rory Spiegel.

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EM Nerd-An Addendum to the Case of the Non-inferior Inferiority

Until recently the management of acute appendicitis has lay squarely in the hands of the surgeon. But there is a growing body of evidence examining the use of antibiotics alone in uncomplicated appendicitis. Most of the data exploring this question has found that the majority of patients treated with antibiotics alone will avoid surgery in […]

EMCrit Project by Rory Spiegel.

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Minding the Gap: A Qualitative Study of Provider Experience to Optimize Care for Critically Ill Children in General Emergency Departments

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


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Anterior intermeniscal ligament: frequency in MRI studies and spatial relationship to the entry point for intramedullary tibial nailing related to the risk of iatrogenic violation

Abstract

Background

Anterior knee pain is the most common complication after intramedullary tibial nailing. Often, the cause is multifactorial and individually different. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible origin of postsurgical anterior knee pain. Both the importance and function of the AIL remain somewhat ambivalent, and even the figures quoted in the literature for its existence in the population vary drastically. Our aim was to verify the estimated frequency of the AIL in the literature by retrospectively analysing the data of MRI studies conducted at our hospital. In addition, we attempted to assess the potential risk of AIL violation during intramedullary tibial nailing, based on the spatial arrangement.

Methods

Two independent examiners analysed the images generated in 351 MRI studies conducted at our hospital between June 2013 and May 2014. All cases who did not reveal any previous knee-joint injury or osteoarthritis of the knee were allocated to group I. All other cases were included in group II. To estimate the potential risk of AIL injury during the nailing procedure, the distance between the AIL and the theoretical entry point for intramedullary nailing was measured.

Results

We identified the AIL on the images of nearly all patients (96.5%) in group I. In group II, the presence of the AIL was confirmed in only 51.4% of cases (p < 0.001). The average distance between the AIL and theoretical entry point for intramedullary tibial nailing was 10.1 mm (range 3.48–18.88 mm).

Conclusions

Because we were able to confirm the presence of the AIL in nearly all patients without a history of knee joint injuries or osteoarthrosis, we presume that the AIL may play a role in knee joint function. Violation of the AIL during intramedullary nailing appears likely due to the close position of the AIL in relation to the entry point for the inserted nail. As a result and due to its rich sensory innervation, a connection between AIL violation during tibial nailing and postoperative onset of anterior knee pain seems likely. To eliminate one risk factor of anterior knee pain development and in view of the unresolved issues of AIL function, violation of the ligament during any operative procedure should be avoided.

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Pyomyositis Diagnosed by Point-of-Care Ultrasound in the Emergency Department

Publication date: Available online 28 September 2018

Source: The Journal of Emergency Medicine

Author(s): Mathew Nelson, David Reens, Allison Cohen

Abstract

Background

Currently, the role of ultrasound in diagnosing superficial abscesses is well validated, however, its role for deep space infections and intramuscular pathology is limited. Distinguishing between simple cellulitis and abscess is critical for emergency physicians (EP), as the treatment is very different. Management of cellulitis relies on antibiotic therapy, whereas abscess treatment requires incision and drainage. It is important that EPs can accurately distinguish between the two entities.

Case Report

We report a case of a 41-year-old man with a history of high blood pressure and poorly controlled diabetes who presented with right lateral thigh redness, warmth, and tenderness. A point-of-care ultrasound (POCUS) of the patient's right lateral thigh with a high-frequency linear (8 MHz) ultrasound probe showed a 2.93 × 3.38 × 6.0-cm complex fluid collection deep to the fascial plane, approximately 3.0 cm from the skin surface, that contained mixed echogenicities with posterior acoustic enhancement consistent with an intramuscular abscess of the vastus lateralis. The patient was diagnosed with pyomyositis of his vastus lateralis. He was started on vancomycin and admitted to the surgical service for antibiotic treatment and surgical drainage.

Why Should Emergency Physicians Be Aware of This?

This case demonstrates that the use of POCUS by EPs can facilitate the rapid recognition and treatment of a disease that is challenging to diagnose on physical examination and can be potentially life-threatening if missed. EPs can consider performing a POCUS when evaluating skin infections to ensure rapid diagnosis and appropriate medical care for a potentially severe condition.

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Febrile Infant with Skin Rash

Publication date: Available online 28 September 2018

Source: The Journal of Emergency Medicine

Author(s): Chin-Yi Juan, Shu-Hsien Kuo, Sai-Wai Ho

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A Uniquely Abnormal Stool Specimen: A Case Report

Publication date: Available online 28 September 2018

Source: The Journal of Emergency Medicine

Author(s): Riley Hoyer, Christopher J. Amann, Andrea L. Austin

Abstract

Background

Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for “passing intestine” just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival.

Case Report

A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after “passing intestine” in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix.

Why Should an Emergency Physician Be Aware of This?

Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

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MedixSafe to exhibit at EMS World Expo Booth #547

Visit us at EMS World Expo Booth #547 to see the latest in narcotics and key security!

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Neonatal abstinence syndrome: Infants falling victim to the opioid crisis

Learn how infants who were exposed to opioids present while suffering from withdrawal

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An outbreak of synthetic cannabinoid–associated coagulopathy in Illinois

New England Journal of Medicine

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Comparison of thick- and thin-slice images in thoracoabdominal trauma CT: a retrospective analysis

Abstract

Purpose

To compare thick (5 mm) and thin slice images (1.5 mm) of lung, soft tissue, and bone window in thoracoabdominal trauma computed tomography.

Materials and methods

167 Patients that underwent thoracoabdominal trauma CT between November 2014 and December 2015 were included in the study. CT data were reconstructed in a transverse direction with 5 mm and 1.5 mm slice images of lung, soft tissue, and bone window. Two blinded raters (radiologists) evaluated the collected data by detecting predefined injuries in different organ areas. Reconstruction and evaluation times as well as detected injuries were noted and compared.

Results

Reconstruction and evaluation times were significantly higher with 1.5 mm thin-slice images, and the effect strength according to Rosenthal displayed a strong effect of 0.61 (< 0.1 small effect, 0.3 middle effect, and > 0.5 strong effect). Average evaluation time differences were 62.7 s (33.9 s–91.5 s) in bone window between 1.5 mm and 3 mm for rater 1 (p < 0.001) and 71.4 s (43.1 s–99.7 s) for rater 2 (p < 0.001). Average time differences between 1.5 mm and 5 mm were 68,7 s (43.9 s–93.5 s) for rater 1 and 75.3 s (44.7 s–105.9 s) for rater 2 in lung window (p < 0.001) and 66.6 s (28.8 s–104.4 s) for rater 1 and 114 s (74.4 s–153.6 s) for rater 2 in soft-tissue window (p < 0.001). There was no significant difference regarding soft-tissue and lung injuries, except non-significant improvement in the detection of bone fractures.

Conclusion

Thin-slice images do not bring any significant benefit in thoracoabdominal trauma CT of soft-tissue and lung injuries, but they can be helpful for the diagnosis of bone fractures and incidental findings.

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What goes in to organizing an EMS conference?

Our co-hosts are joined by EMS educator Joshua Ishmael, who coordinated this year's St. Elizabeth EMS Conference in Cincinnati, Ohio

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What goes in to organizing an EMS conference?

Our co-hosts are joined by EMS educator Joshua Ishmael, who coordinated this year's St. Elizabeth EMS Conference in Cincinnati, Ohio

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Cardiac arrest teams perspectives on communication and ethical conflicts related to awareness during CPR, a focus group study protocol

Awareness during Cardio Pulmonary Resuscitation (CPR) also called CPR induced consciousness (CPRIC) is a rare, but increasingly reported condition with significant clinical implications. Health professionals l...

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Roundtable: Experts reflect on findings, trends from the 2018 EMS Trend Report

Our EMS expert panel identifies actions EMS leaders can take to improve clinical and operational performance, and to advance the profession

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Roundtable: Experts reflect on findings, trends from the 2018 EMS Trend Report

Our EMS expert panel identifies actions EMS leaders can take to improve clinical and operational performance, and to advance the profession

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Providers vs. Leaders: Trend report reveals divide on issues of safety, fatigue, mental health

An organization’s leadership culture may explain the stark difference in opinion between providers and leaders on issues of patient and provider safety

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Solutions for EMS recruitment and retention are hiding in plain sight

Even though the race to recruit, hire, engage and retain EMS employees is as intense as ever, there are working solutions within reach for every agency

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How do providers and leaders perceive EMS?

The 2018 EMS Trend Report asks EMS field providers, as well as leaders and chiefs, about their perceptions of the state of EMS in the U.S.

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Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

The effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative...

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Beneficial effects of antioxidant therapy in crush syndrome in a rodent model: enough evidences to be used in humans?

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How do providers and leaders perceive EMS?

The 2018 EMS Trend Report asks EMS field providers, as well as leaders and chiefs, about their perceptions of the state of EMS in the U.S.

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How do providers and leaders perceive EMS?

The 2018 EMS Trend Report asks EMS field providers, as well as leaders and chiefs, about their perceptions of the state of EMS in the U.S.

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Cape and Skyfire Consulting team up to support end-to-end drone integration for public safety

REDWOOD CITY, Calif. — Cape, the leading cloud platform for drone telepresence and data management, today announced a partnership with Skyfire Consulting to provide comprehensive technology solutions and support for the safe integration of commercial drones across public safety agencies, including law enforcement, fire rescue, and emergency management services. As part of the partnership,...

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Hemodynamic consequences of extremity injuries following a terrorist bombing attack: retrospective cohort study

Abstract

Background

Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries.

Methods

Retrospective study based on a cohort of patient records maintained in one hospital’s mass casualty registry.

Results

Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2–22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3–4 were found to be risk factors for HS.

Conclusions

Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.

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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

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Randomized clinical trial comparing procedural amnesia and respiratory depression between moderate and deep sedation with propofol in the Emergency Department

Academic Emergency Medicine

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Prevalence of post-traumatic stress disorder, acute stress disorder and depression following violence related injury treated at the Emergency Department: A systematic review

BMC Psychiatry

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IBCC chapter & cast: community-onset pneumonia

Sir William Osler called pneumonia "the captain of the men of death."  Over a century later, pneumonia remains the leading cause of infectious death in the developed world.  

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: community-onset pneumonia

Sir William Osler called pneumonia "the captain of the men of death."  Over a century later, pneumonia remains the leading cause of infectious death in the developed world.  

EMCrit Project by Josh Farkas.

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Capturing Emergency Department Discharge Quality with the Care Transitions Measure: A Pilot Study

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


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EMS community donates clothing, boots and money to paramedic students in need

EMS professionals, educators rally to support and “take care of the next generation of providers”

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Health Related Quality of Life in Children After Burn Injuries: A Systematic Review

Background Through improved survival of burns, more children have to deal with consequences of burns. Health-related quality of life (HRQL) measurement is important to qualify the perceived burden of burns in children. No systematic study of this outcome in children exist. Therefore, our objective was to review study designs, instruments, methodological quality, outcomes and predictors of HRQL in children after burns. Methods A systematic literature search was conducted in CINAHL, Embase, Google Scholar, Medline, The Cochrane library and Web of science (PROSPERO ID=CRD42016048065). Studies examining HRQL in pediatric burn patients were included. The risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Results Twenty-seven studies using twelve HRQL instruments were included. The Burns Outcome Questionnaire 0-4 and 5-18 years old were most often applied. All longitudinal studies showed improvement of HRQL over time. However, problems were reported on the longer term on the domains '(parental) concern' and 'appearance'. Parental proxy scores were in general comparable to children’s self-ratings. Severity of burns, facial burns, hand burns, comorbidity and short time since burn predicted an impaired HRQL. The risk of bias of the studies was in general moderate. Conclusions HRQL in children after burns increases over time. Domains and patient groups that require special attention are identified. However, due to lack of comparability of studies, the available information could not be used optimally. To further improve our understanding of HRQL, consensus on design, data-analysis and data presentation is needed. Level of evidence Systematic review, level III Email addresses:spronki@maasstadziekenhuis.nl, legematec@maasstadziekenhuis.nl, s.polinder@erasmusmc.nl, baarm@maasstadziekenhuis.nl *Corresponding author: Inge Spronk, Association of Dutch Burn centers, Maasstad Hospital, PO Box 9100, 3007 AC Rotterdam, the Netherlands, Tel. 00 31 10 291 2739, Email: spronki@maasstadziekenhuis.nl. Conflict of Interest: None declared. Funding source: All phases of this study were supported by The Dutch Burn Foundation (grant number: 15.102 to MvB). The funding source had no role in any part of the study. © 2018 Lippincott Williams & Wilkins, Inc.

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EMS community donates clothing, boots and money to paramedic students in need

EMS professionals, educators rally to support and “take care of the next generation of providers”

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Acela Truck Company expands it's line of high water/flood rescue trucks

BOZEMAN, Mont. — Acela Truck Company recently announced that it has expanded its purpose-built High Water/Flood Rescue Truck line of response apparatus to include multiple new custom body configurations and larger 6x6 models of its Monterra high mobility chassis. Flooding is the leading cause of disaster or weather-related deaths in the United States and the number of coastal and inland...

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Executive Director - Simsbury Vol. Ambulance Asso.

SVAA Mission: The Simsbury Volunteer Ambulance Association is a non-profit organization serving the emergency medical needs for the Town of Simsbury, CT. The Mission of SVAA is to continue to deliver the highest quality of emergency medical care to the town with a 100% response rate on first calls, while adhering to all state and local medical compliance regulations. Position Summary: The Executive ...

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Instructions for Authors

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department The CHARMED Cluster Randomized Trial: Freund Y, Goulet H, Leblanc J, et al. JAMA Intern Med. 2018;178(6):812-819

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): James Engeln

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Adherence to Advanced Cardiovascular Life Support (ACLS) Guidelines During In-Hospital Cardiac Arrest is Associated with Improved Outcomes: Honarmand K, Mepham C, Ainsworth C, Khalid Z. Resuscitation. 2018;129:76-81

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): James Engeln

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Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children: Bhatt M, Johnson DW, Taljaard M, et al. JAMA Pediatr. 2018;172(7):678-685

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): James Engeln

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Impact of Night Shifts on Emergency Medicine Resident Resuscitation Performance: Edgerley S, McKaigney C, Boyne D, et al. Resuscitation. 2018; 127:26-30

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Nikolaus Matsler

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Fewer Adverse Effects with a Modified Two-Bag Acetylcysteine Protocol in Paracetamol Overdose: McNulty R, Lim J, Chandru P, Gunja N. Clin Toxicol. 2018; 56(7):618-21

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Nikolaus Matsler

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Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis: Kuppermann N, Ghetti S, Schunk JE, et al. N Engl J Med. 2018; 378(24):2275-2287

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Nikolaus Matsler

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The safety of high-dose insulin euglycemia therapy in toxin-induced cardiac toxicity: Page CB, Ryan NM, Ibister GK. Clin Toxicol. 2018; 56(6):389-396

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Reid Armstrong Haflich

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Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: Cameron DB, Melvin P, Graham DA, et al. Ann Surg. 2018;268(1):186-192

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Reid Armstrong Haflich

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Development and Validation of a Calculator for Estimating Probability of Urinary Tract Infections in Young Febrile Children: Shaikh N, Hoberman A, Hum SW, et al. JAMA Pediatr. 2018; 172(6):550-556

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Reid Armstrong Haflich

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Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging: Clemency BM, Tanski CT, Gibson Chambers J, et al. Prehosp Emerg Care. 2018; 22(4):506-510

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Jeremy Collado

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Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection: Huang DT, Yealy DM, Filbin MR, et al. N Engl J Med. 2018; 379(3):236-249

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Jeremy Collado

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Association Between Ventricular Fibrillation Amplitude Immediately Prior to Defibrillation and Defibrillation Success in Out-of-hospital Cardiac Arrest: Balderston JR, Gertz ZM, Ellenbogen KA, et al. Am Heart. J 2018;201:72-76

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s): Jeremy Collado

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JEM_Oct18_v2-hires.pdf

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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Contents

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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Issue Highlights

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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Editorial Board

Publication date: October 2018

Source: The Journal of Emergency Medicine, Volume 55, Issue 4

Author(s):

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Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature

Publication date: Available online 26 September 2018

Source: The Journal of Emergency Medicine

Author(s): Brit Long, Alex Koyfman, Michael Gottlieb

Abstract

Background

Acute heart failure (AHF) is a common presentation to the emergency department (ED), with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.

Objectives

This review provides an evidence-based summary of the current ED management of acute heart failure.

Discussion

Heart failure can present along a spectrum, especially in acute exacerbation. Treatment should focus on the underlying disease process, with guidelines focusing primarily on blood pressure and hemodynamic status. Treatment of patients with mild AHF exacerbations often focuses on intravenous diuretics. Patients with AHF with flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension. Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250–500 mL, followed by initiation of inotropic agents with or without vasopressors. Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed. If noninvasive positive pressure ventilation is required, providers should monitor closely for acute decompensation. Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention. High-output heart failure can be managed acutely with vasoconstricting agents, with focus on treating the underlying etiology. Disposition is not always straightforward, and several risk scores may assist in this decision.

Conclusion

AHF is a condition that requires rapid assessment and management. Understanding the appropriate management strategy can allow for more targeted treatment and improved outcomes.

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Acute Pancreatitis: Updates for Emergency Clinicians

Publication date: Available online 26 September 2018

Source: The Journal of Emergency Medicine

Author(s): Anna Waller, Brit Long, Alex Koyfman, Michael Gottlieb

Abstract

Background

Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis.

Objective

This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis.

Discussion

Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe.

Conclusions

Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.

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A novel method of non-clinical dispatch is associated with a higher rate of critical Helicopter Emergency Medical Service intervention

Helicopter Emergency Medical Services (HEMS) are a scarce resource that can provide advanced emergency medical care to unwell or injured patients. Accurate tasking of HEMS is required to incidents where advanc...

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Variation in Case-Mix Adjusted Unplanned Pediatric Cardiac ICU Readmission Rates

Objectives: To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals Design: Retrospective cohort study using prospectively collected clinical registry data Setting: Pediatric Cardiac Critical Care Consortium clinical registry. Patients: Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals. Interventions: None. Measurements and Main Results: We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (

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Systemic Inflammatory Response Syndrome as Predictor of Poor Outcome in Nontraumatic Subarachnoid Hemorrhage Patients

Objectives: Subarachnoid hemorrhage is a life-threatening disease associated with high mortality and morbidity. A substantial number of patients develop systemic inflammatory response syndrome. We aimed to identify risk factors for systemic inflammatory response syndrome development and to evaluate the role of systemic inflammatory response syndrome on patients’outcome. Design: Retrospective observational cohort study of prospectively collected data. Setting: Neurocritical care unit at a tertiary academic medical center. Patients: Two-hundred and ninety-seven consecutive nontraumatic subarachnoid hemorrhage patients admitted to the neurologic ICU between 2010 and 2017. Interventions: Systemic inflammatory response syndrome was diagnosed based on greater than or equal to two criteria (hypo-/hyperthermia, tachypnea, leukopenia/leukocytosis, tachycardia) and defined as early (≤ 3 d) and delayed (days 6–10) systemic inflammatory response syndrome burden (systemic inflammatory response syndrome positive days within the first 10 d). Using multivariate analysis, risk factors for the development of early and delayed systemic inflammatory response syndrome and the relationship of systemic inflammatory response syndrome with poor 3-month functional outcome (modified Rankin Scale score ≥ 3) were analyzed. Measurements and Main Results: Seventy-eight percent of subarachnoid hemorrhage patients had early systemic inflammatory response syndrome, and 69% developed delayed systemic inflammatory response syndrome. Median systemic inflammatory response syndrome burden was 60% (interquartile range, 10–90%). Risk factors for early systemic inflammatory response syndrome were higher admission Hunt and Hess grade (odds ratio, 1.75; 95% CI, 1.09–2.83; p = 0.02), aneurysm clipping (odds ratio, 4.84; 95% CI, 1.02–23.05; p = 0.048), and higher modified Fisher Scale score (odds ratio, 1.88; 95% CI, 1.25–2.89; p = 0.003). Hunt and Hess grade and pneumonia were independently associated with delayed systemic inflammatory response syndrome development. Systemic inflammatory response syndrome burden (area under the curve, 0.84; 95% CI, 0.79–0.88) had a higher predictive value for 3-month poor outcome compared with early systemic inflammatory response syndrome (area under the curve, 0.76; 95% CI, 0.70–0.81; p

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Aortic Branch Vessel Flow During Resuscitative Endovascular Balloon Occlusion of the Aorta

Background REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) is a torso hemorrhage control adjunct. Aortic branch vessel flow (BVF) during REBOA is poorly characterized and has implications for ischemia-reperfusion (I-R) injury. The aim of this study is to quantify branch vessel flow in hypovolemic shock with and without REBOA. Methods Female swine (79-90kg) underwent anesthesia, 40% controlled hemorrhage and sonographic flow monitoring of the carotid, hepatic, superior mesenteric, renal and femoral arteries. Animals were randomized to REBOA (n=5) or no-REBOA (n=5) for 4 hours, followed by full resuscitation and balloon deflation for 1-hour. Results All animals were successfully induced into hemorrhagic shock with a mean decrease of flow in all vessels of 50% from baseline (p

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Effects of a restrictive blood transfusion protocol on acute pediatric burn care

Background Blood transfusion is costly and associated with various medical risks. Studies in critically ill adult and pediatric patients suggest that implementation of more restrictive transfusion protocols based on lower threshold hemoglobin concentrations can be medically and economically advantageous. The purpose of this study was to evaluate the implications of a hemoglobin threshold change in pediatric burn patients. Methods We implemented a change in hemoglobin threshold from 10 to 7 g/dL and compared data from patients before and after this protocol change in a retrospective review. Primary endpoints were hemoglobin concentration at baseline, before transfusion, and after transfusion; amount of blood product administered; and mortality. Secondary endpoints were the incidence of sepsis based on the American Burn Association physiological criteria for sepsis and mean number of septic days per patient. All endpoint analyses were adjusted for relevant clinical covariates via generalized additive models or Cox proportional hazard model. Statistical significance was accepted at p 0.05) were comparable between groups. The group transfused based on the more restrictive hemoglobin threshold had lower hemoglobin concentrations before and after transfusion throughout acute hospitalization, received lower volumes of blood during operations (pre: 1012 mL, post: 824 mL; p

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Ford creates system to alert drivers to oncoming emergency vehicles

The new system helps drivers give emergency vehicles a route through traffic by forming an “emergency corridor”

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Mucosal Injury From Calcium Oxalate Crystals Resembling Anaphylaxis and Angioedema

Publication date: Available online 24 September 2018

Source: The Journal of Emergency Medicine

Author(s): Vincent Ceretto, Nicholas Nacca

Abstract

Background

There are 215 families of plants that contain insoluble needle-shaped calcium oxalate crystals on the surface of their tissues. Upon mucosal contact, injury can cause extreme pain, soft-tissue swelling, salivation, dysphagia, and even aphonia. This presentation can resemble angioedema or anaphylaxis.

Case Report

A 55-year-old Asian female presented to the emergency department complaining of oral pain, swelling, and numbness. Her family reported that she began to experience sharp pain of the tongue and lips immediately after eating “elephant root.” Physical examination revealed a patient sitting in an upright position, leaning forward with pooling secretions. She had few lingual petechiae, a subtle diffuse erythema, and mild edema of the lower lip. Due to pain, she was unable to speak and swallow. Her vitals remained within normal limits. The patient was taking lisinopril for hypertension.

Why Should An Emergency Physician Be Aware of This?

Injury by calcium oxalate crystals is a relatively common occurrence that will present to the emergency department. Although most exposures are benign, patients can develop critical illness, requiring emergent therapies and airway management. Due to the nature of presentation, exposure can easily be misdiagnosed as anaphylaxis or hereditary and drug-induced angioedema. Severe pain and the temporal relationship to plant ingestion distinguish insoluble calcium oxalate crystal exposure from these alternative causes of angioedema. There is minimal evidence-based data evaluating treatment of these injuries. Standard treatment regimen includes a local anesthetic, corticosteroids, opioids, and antihistaminergic agents. Given the relative low cost, ease of administration, and benign adverse effect profile, sodium bicarbonate rinse may have a role as an adjunct therapy, however, research is needed.

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Rash and Thrombocytopenia

Publication date: Available online 24 September 2018

Source: The Journal of Emergency Medicine

Author(s): Margot Samson, Susan R. Wilcox, Shan W. Liu

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High prevalence of bacteria in clinically aseptic non-unions of the tibia and the femur in tissue biopsies

Abstract

Purpose

There are several hints that bacterial colonization might be an often overseen cause of non-union. Modern procedures like PCR have been reported to diagnose bacterial colonization with a high degree of accuracy. While PCR is not ubiquitously available, we hypothesize that biopsies from the non-union site are comparable to PCR results reported in the literature.

Methods

Retrospective analysis of microbiological results of biopsies from non-unions (femoral or tibial, history of revision surgery, and/or open fracture) with stable osteosynthesis, no clinical signs of local infection were analysed. CRP and leucocyte count were taken on admission. Multiple tissue samples (soft tissue and bone) were from the non-union (1–4 cm incision). Samples were cultivated for 2 weeks and tested following EUCAST protocols using VITEK^® 2.

Results

11 tibia- and 7 femur non-union (44 ± 23.9 years), 11 open fractures (1 I°, 6 II°, 4 III° Gustillo Anderson), 0–5 revisions, and 4.1 (± 1.8) tissue samples were taken 8.5 (± 1.7) months after trauma. Cultures were positive in 8/18 (44,4%) (3/18 Propionibacterium acnes, 1/18 S. capitis, and 4/18 S. epidermidis). There was neither a correlation between number of biopsies taken and positive culture results (Pearson R: − 0.0503, R² 0.0025), nor between positive culture results and leucocytes counts (Pearson R: − 0.0245, R² 0.0006) or CRP concentration (Pearson R: 0.2823, R² 0.0797).

Conclusion

The results confirm that the presence of bacteria in cases with no clinical signs of infection is a relevant issue. The prevalence of bacteria reported here is comparable that reported from cohorts tested with PCR or sonication. In most cases, there was only one positive biopsy, raising the question whether a contamination has been detected. Thus, to better understand the problem, it is necessary to gather more knowledge regarding the sensitivities and specificities of the different diagnostic procedures.

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Impact of pre-hospital vital parameters on the neurological outcome of out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry

Resuscitation

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Predicting in-hospital mortality and unanticipated admissions to the intensive care unit using routinely collected blood tests and vital signs: Development and validation of a multivariable model

Resuscitation

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Long-term neurological outcomes in out-of-hospital cardiac arrest patients treated with targeted-temperature management

Resuscitation

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CLEARED (Chemicals and Litmus testing with Effective Alkaline Range for Eye Damage): a prospective, interventional study

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


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Predictors of survival in patients with influenza pneumonia-related severe acute respiratory distress syndrome treated with prone positioning

Patients with influenza complicated with pneumonia are at high risk of rapid progression to acute respiratory distress syndrome (ARDS). Prone positioning with longer duration and lung-protective strategies mig...

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3 ways telemedicine can increase the reach of your EMS agency

Improve access to care and triage less urgent calls for more efficient use of healthcare resources

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Postoperative complications of intestinal anastomosis after blunt abdominal trauma

Abstract

Background

Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma.

Method

We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications.

Results

A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01–1.60; p = 0.04) was found to be the independent predictor of postoperative complications.

Conclusion

Repair of traumatic blunt bowel injury remains a surgical challenge.

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A new tailored protocol based on laparoscopy in the management of abdominal shotgun injuries: a case-series study

Abstract

Purpose

Abdominal shotgun injuries derive their significance from the wide range of injuries they cause. The management of this type of injury has been continuously evolving. Despite the ongoing incorporation of laparoscopy in management of abdominal trauma, there is no definite protocol raising the role of laparoscopy in such injuries. In this study, we outlined a tailored protocol in the management of penetrating abdominal shotgun injuries differing from the previous protocols which comprised either mandatory exploration or non-operative management.

Patients and methods

This case-series study included patients who attended to our emergency department with a shotgun injury involving the abdomen between December 2014 and October 2016. Only stable patients with no clinical signs of surgical abdomen, in combination with CT evidence of penetrating intra-abdominal pellets, were subjected to laparoscopic exploration in this study.

Results

Thirty patients fulfilled the inclusion criteria. During laparoscopy, ten patients were designated as positive for injuries. No missed injuries were identified. Two of the cases identified as positive by laparoscopy needed no further management while the remaining eight patients warranted laparotomy. Only one of these eight patients turned out to have a non-therapeutic exploration. Consequently, laparoscopy in the management of these injuries had an overall accuracy of 96.7%, sensitivity of 100%, specificity of 95.7%, positive predictive value of 87.5% and negative predictive value of 100% with highly significant p value < 0.001.

Conclusion

A tailored protocol relying on the use of laparoscopy in the management of stable patients with CT evidence of penetrating abdominal shotgun injuries is safe and helps to cut down the number of non-therapeutic laparotomies with consequent decrease of complications.

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Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial

Abstract

Purpose

The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2–4 ankle fractures.

Methods

A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications.

Results

The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O’Brien–Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications.

Conclusions

Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

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PulmCrit- Solving the OPTALYSE PE riddle: We’re dosing tPA wrong

Occasionally in science we encounter a truly bizarre result.  Our natural inclination is to ignore the bizarre result.  It’s jarring.  It creates cognitive dissonance, challenging our understanding of the world.  However, struggling to understand the bizarre result can reset our perspective.  It’s often the bizarre, unexpected result that changes everything. 

EMCrit Project by Josh Farkas.

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Outcome of conscious survivors of out-of-hospital cardiac arrest

Resuscitation

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PulmCrit- Solving the OPTALYSE PE riddle: We’re dosing tPA wrong

Occasionally in science we encounter a truly bizarre result.  Our natural inclination is to ignore the bizarre result.  It’s jarring.  It creates cognitive dissonance, challenging our understanding of the world.  However, struggling to understand the bizarre result can reset our perspective.  It’s often the bizarre, unexpected result that changes everything. 

EMCrit Project by Josh Farkas.

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Blunt splenic injury in children: haemodynamic status key to guiding management, a 5-year review of practice in a UK major trauma centre

Abstract

Purpose

To review the management of children and adolescents (0–18 years), with blunt splenic injury treated at a single UK major trauma centre over a 5-year period, focusing upon efficacy of non-operative management and the use of haemodynamic stability as a guide to planning treatment strategy, rather than radiological injury grading. To produce a treatment pathway for management of blunt splenic injury in children.

Methods

Retrospective, cross-sectional study of all paediatric patients admitted with radiologically proven blunt splenic injury between January 2011 and March 2016. Penetrating injuries were excluded. Follow up was for at least 30 days.

Results

30 Patients were included, mean age was 14.5 (SD 3.6), median injury severity score was 16 (IQR 10–31). 6 Patients (20%) had a splenectomy, whilst 22 patients (73%) were successfully treated non-operatively with 100% efficacy at index admission. 5/8 (63%) patients with radiological grade V injuries were managed non-operatively, injury grade was not associated with surgical intervention (p = 1.57). Haemodynamic instability was initially treated with fluid resuscitation leading to successful non-operative management in 5/11 (45%) patients. However, haemodynamic instability is a significant predictor of requirement for surgical intervention (p = 0.03), admission to critical care (p = 0.017), presence of additional injuries (p = 0.015) and increased length of stay (p = 0.038). No such relationships were found to be associated with increased radiological injury grade.

Conclusions

Non-operative management should be first-line treatment in the haemodynamically stable child with a blunt splenic injury and may be carried out with a high degree of efficacy. It may also be successfully implemented in those initially showing signs of haemodynamic instability that respond to fluid resuscitation. Radiological injury grade does not predict definitive management, level of care, or length of stay; however, haemodynamic stability may be utilised to produce a treatment algorithm and is key to guiding management.

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Negative FAST Exam Predicts Successful Non-operative Management in Pediatric Solid Organ Injury: A Prospective ATOMAC+ Study

Introduction FAST exam has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST exam in predicting the success or failure of non-operative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population. Methods A retrospective analysis of a prospective observational study of patients less than 18 years of age presenting with BLSI to one of ten level-1 pediatric trauma centers (PTC) between April 2013 and January 2016. 1008 patients were enrolled and 292 had a FAST exam recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST exam alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI. Results FAST exam had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST exam was 4.9 and with a negative FAST was 0.20. When combined with SIPA a positive FAST exam and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had a NPV of 96% and the odds ratio for failure was 0.20. Conclusion Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the positive or negative predictive value significantly. FAST exam may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting. Level of Evidence Level II, Prognostic Study Corresponding Author and Address for Reprints: Robert W. Letton, Jr., MD, Division of Pediatric Surgery, 1200 Everett Drive, Suite NP 2320, Oklahoma City, OK 73104; Robert-letton@ouhsc.edu; 405-271-5922. Conflicts of Interest: The authors declare there are no conflicts of interest to report Meeting Presented: 3rd Annual Meeting of the Pediatric Trauma Society meeting, November 11-12, 2016, in Nashville, TN Funding: Not-applicable © 2018 Lippincott Williams & Wilkins, Inc.

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Emergency Response Teams In and Outside of Medicine - Structurally Crafted To Be Worlds Apart

Medical Emergency Response Teams (MERTs) are widespread throughout inpatient hospital care facilities. Besides the rise of the ubiquitous rapid response team, current MERTs span trauma, stroke, myocardial infarction, and sepsis in many hospitals. Given the multiplicity of teams with widely varying membership, leadership, and functionality, the structure of MERTs is appropriate to review to determine opportunities for improvement. Since non-medical ERTs predate MERT genesis, and are similar across multiple disciplines, non-medical ERTs provides a standard against which to compare and review MERT design and function. Non-medical ERTs are crafted to leverage team members who are fully trained and dedicated to that domain, whose skills are regularly updated, with leadership tied to unique skill sets rather than based on hierarchical rank; activity is immediately reviewed at the conclusion of each deployment and teams continue to work together between team deployments. MERTs, in sharp contradistinction, often incorporate trainees into teams that do not train together, are not focused on the discipline required to be leveraged, are led based on arrival time or hierarchy, and are usually reviewed at a time remote from team action; teams rapidly disperse after each activity and generally do not continue to work together in between team activations. These differences between ERTs and MERTs may impede MERT success with regard to morbidity and mortality mitigation. Readily deployable approaches to bridge identified gaps include dedicated Advanced Practice Provider (APP) team leadership, reductions in trainee MERT leadership while preserving participation, discipline-dedicated rescue teams, and inter-team integration training. Emergency response teams in medical and non-medical domains share parallels yet lack congruency in structure, function, membership, roles, and performance evaluation. MERT structural redesign may be warranted to embrace the beneficial elements of non-medical ERTs to improve patient outcome and reduce variation in rescue practices and team functionality. Study type narrative review Level of Evidence N/A No authors have a conflict of interest to declare This is an unfunded review article Address correspondence to: Lewis J. Kaplan, MD, FACS, FCCM, FCCP, Professor of Surgery, Perelman School of Medicine, University of Pennsylvania, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, Lewis.Kaplan@uphs.upenn.edu Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, Lewis.Kaplan@va.gov, Tele: (215) 823-6084, FAX (215) 823-4309 © 2018 Lippincott Williams & Wilkins, Inc.

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Patient Uncertainty as a Predictor of 30‐day Return Emergency Department Visits: An Observational Study

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


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Long-Term Functional Outcome Data Should Not in General Be Used to Guide End-of-Life Decision-Making in the ICU

No abstract available

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Peripherally Inserted Central Catheters in the ICU: A Retrospective Study of Adult Medical Patients in 52 Hospitals

Objectives: To quantify variation in use and complications from peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the general ward. Design: Retrospective cohort study. Setting: Fifty-two hospital Michigan quality collaborative. Patients: Twenty-seven–thousand two-hundred eighty-nine patients with peripherally inserted central catheters placed during hospitalization. Measurements and Main Results: Descriptive statistics were used to summarize patient, provider, and device characteristics. Bivariate tests were used to assess differences between peripherally inserted central catheters placed in the ICU versus peripherally inserted central catheters placed on the ward. Multilevel mixed-effects generalized linear models adjusting for patient and device factors with a logit link clustered by hospital were used to examine the association between peripherally inserted central catheter complications and location of peripherally inserted central catheter placement. Variation in ICU peripherally inserted central catheter use, rates of complications, and appropriateness of use across hospitals was also examined. Eight-thousand two-hundred eighty patients (30.3%) received peripherally inserted central catheters in the ICU versus 19,009 (69.7%) on the general ward. The commonest indication for peripherally inserted central catheter use in the ICU was difficult IV access (35.1%) versus antibiotic therapy (53.3%) on wards. Compared with peripherally inserted central catheters placed in wards, peripherally inserted central catheters placed in the ICU were more often multilumen (59.5% vs 39.3; p

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Evaluation of a Measurement System to Assess ICU Team Performance

Objective: Measuring teamwork is essential in critical care, but limited observational measurement systems exist for this environment. The objective of this study was to evaluate the reliability and validity of a behavioral marker system for measuring teamwork in ICUs. Design: Instances of teamwork were observed by two raters for three tasks: multidisciplinary rounds, nurse-to-nurse handoffs, and retrospective videos of medical students and instructors performing simulated codes. Intraclass correlation coefficients were calculated to assess interrater reliability. Generalizability theory was applied to estimate systematic sources of variance for the three observed team tasks that were associated with instances of teamwork, rater effects, competency effects, and task effects. Setting: A 15-bed surgical ICU at a large academic hospital. Subjects: One hundred thirty-eight instances of teamwork were observed. Specifically, we observed 88 multidisciplinary rounds, 25 nurse-to-nurse handoffs, and 25 simulated code exercises. Interventions: No intervention was conducted for this study. Measurements and Main Results: Rater reliability for each overall task ranged from good to excellent correlation (intraclass correlation coefficient, 0.64–0.81), although there were seven cases where reliability was fair and one case where it was poor for specific competencies. Findings from generalizability studies provided evidence that the marker system dependably distinguished among teamwork competencies, providing evidence of construct validity. Conclusions: Teamwork in critical care is complex, thereby complicating the judgment of behaviors. The marker system exhibited great potential for differentiating competencies, but findings also revealed that more context specific guidance may be needed to improve rater reliability. This work was performed at the Johns Hopkins University. Portions of the data collection and analyses that are reported were a part of Dr. Dietz’s dissertation work. The views presented in this article are those of the authors and do not necessarily reflective of the Johns Hopkins University, Johns Hopkins Hospital, Rice University, the University of Central Florida, or the Gordon and Betty Moore Foundation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by grants from the Gordon and Betty Moore Foundation (grant number: 3186.01). Dr. Dietz and Ms. Dwyer’s institutions received funding from the Gordon and Betty Moore Foundation. Dr. Mendez-Tellez received support for article research from the National Institutes of Health. Ms. Dwyer received support for article research from the Gordon and Betty Moore Foundation. Dr. Rosen’s institution received funding from the Gordon and Betty Moore Foundation (grant number: 3186.01), Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, and Jhpiego - Global Health Services, Treatment & Prevention; and he disclosed that he is a co-investigator on a project funded through the National Aeronautics and Space Administration. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: mrosen44@jhmi.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Estimating the False Positive Rate of Absent Somatosensory Evoked Potentials in Cardiac Arrest Prognostication

Objectives: Absence of somatosensory evoked potentials (“absent somatosensory evoked potentials”) is considered a nearly perfect predictor of poor outcome after cardiac arrest. However, reports of good outcomes despite absent somatosensory evoked potentials and high rates of withdrawal of life-sustaining therapies have raised concerns that estimates of the prognostic value of absent somatosensory evoked potentials may be biased by self-fulfilling prophecies. We aimed to develop an unbiased estimate of the false positive rate of absent somatosensory evoked potentials as a predictor of poor outcome after cardiac arrest. Data Sources: PubMed. Study Selection: We selected 35 studies in cardiac arrest prognostication that reported somatosensory evoked potentials. Data Extraction: In each study, we identified rates of withdrawal of life-sustaining therapies and good outcomes despite absent somatosensory evoked potentials. We appraised studies for potential biases using the Quality in Prognosis Studies tool. Using these data, we developed a statistical model to estimate the false positive rate of absent somatosensory evoked potentials adjusted for withdrawal of life-sustaining therapies rate. Data Synthesis: Two-thousand one-hundred thirty-three subjects underwent somatosensory evoked potential testing. Five-hundred ninety-four had absent somatosensory evoked potentials; of these, 14 had good functional outcomes. The rate of withdrawal of life-sustaining therapies for subjects with absent somatosensory evoked potential could be estimated in 14 of the 35 studies (mean 80%, median 100%). The false positive rate for absent somatosensory evoked potential in predicting poor neurologic outcome, adjusted for a withdrawal of life-sustaining therapies rate of 80%, is 7.7% (95% CI, 4–13%). Conclusions: Absent cortical somatosensory evoked potentials do not infallibly predict poor outcome in patients with coma following cardiac arrest. The chances of survival in subjects with absent somatosensory evoked potentials, though low, may be substantially higher than generally believed. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health. Drs. Bianchi and Westover are co-senior authors. 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 National Institutes of Health 1K23NS090900, T32HL007901, T90DA22759, T32EB001680; Neurocritical Care Society research training fellowship; American Heart Association postdoctoral fellowship; Andrew David Heitman Neuroendovascular Research Fund; Rappaport Foundation; and Salerno foundation. Dr. Amorim is supported by the Neurocritical Care Society and the American Heart Association. Dr. Amorim’s institution received funding from the National Institutes of Health (NIH), Neurocritical Care Society, and the American Heart Association; he disclosed he is supported by the Andrew David Heitman Neuroendovascular Research Fund, Rappaport Foundation, and Salerno foundation. Dr. Ghassemi is supported by the Salerno foundation. Dr. Lee’s institution received funding from the NIH-NINDS (R03NS091864), and he received funding from SleepMed/DigiTrace and Advance Medical. Dr. Greer received funding from Bard Medical (research grant), and he received funding from medical-legal consultation. Dr. Kaplan received funding from Wiley Blackwell (royalties), Cadwell, and Lundbeck; and as an expert witness on quantitative electroencephalogram. Dr. Cash received support from NIH-National Institute of Neurological Diseases and Stroke (NINDS) NINDS RO1-NS062092, and NINDS-K24-NS088568). Dr. Westover received support from the NIH (1K23NS090900, 1R01NS102190, 1R01NS102574, 1R01NS107291), Andrew David Heitman Neuroendovascular Research Fund, and Rappaport Foundation. Drs. Amorim, Ghassemi, Cole, and Westover received support for article research from the NIH. Dr. Bianchi received support from the Massachusetts General Hospital, the Center for Integration of Medicine and Innovative Technology, the Milton Family Foundation, and the American Sleep Medicine Foundation; he has a patent pending on a home sleep monitoring device; he has received travel funding from Servier; has consulting and research contracts with Foramis, MC10, Insomnisolv, International Flavors and Fragrances, and GrandRounds; and has provided expert testimony in sleep medicine. For information regarding this article, E-mail: edilbertoamorim@gmail.com Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Combining National Early Warning Score With Soluble Urokinase Plasminogen Activator Receptor (suPAR) Improves Risk Prediction in Acute Medical Patients: A Registry-Based Cohort Study

Objectives: Soluble urokinase plasminogen activator receptor is a prognostic biomarker associated with critical illness, disease progression, and risk of mortality. We aimed to evaluate whether soluble urokinase plasminogen activator receptor adds prognostic value to a vital sign-based score for clinical monitoring of patient risk (National Early Warning Score) in acute medical patients. Design: Registry-based observational cohort study of consecutively admitted acute medical patients. Setting: The Acute Medical Unit, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark. Patients: Acute medical patients admitted between November 18, 2013, and September 30, 2015. Interventions: None. Measurements and Main Results: Of 17,312 included patients, admission National Early Warning Score was available for 16,244 (93.8%). During follow-up, 587 patients (3.4%) died in-hospital, 859 (5.0%) within 30 days, and 1,367 (7.9%) within 90 days. High soluble urokinase plasminogen activator receptor was significantly associated with in-hospital-, 30-day-, and 90-day mortality within all National Early Warning Score groups, in particular in patients with a low National Early Warning Score; for 30-day mortality, mortality rate ratios ranged from 3.45 (95% CI, 2.91–4.10) for patients with National Early Warning Score 0–1, to 1.86 (95% CI, 1.47–2.34) for patients with National Early Warning Score greater than or equal to 9 for every doubling in soluble urokinase plasminogen activator receptor (log2-transformed). Combining National Early Warning Score, age, and sex with soluble urokinase plasminogen activator receptor improved prediction of in-hospital-, 30-day-, and 90-day mortality, increasing the area under the curve (95% CI) for 30-day mortality from 0.86 (0.85–0.87) to 0.90 (0.89–0.91), p value of less than 0.0001, with a negative predictive value of 99.0%. Conclusions: The addition of soluble urokinase plasminogen activator receptor to National Early Warning Score significantly improved risk prediction of both low- and high-risk acute medical patients. Patients with low National Early Warning Score but elevated soluble urokinase plasminogen activator receptor had mortality risks comparable to that of patients with higher National Early Warning Score. 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. The study was performed at the Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark. The funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Drs. Rasmussen and Haupt have received funding for travel from ViroGates A/S, Denmark, the company that produces the suPARnostic assays; she is supported by a grant from the Lundbeck Foundation (grant number R180-2014–3360). Mr. Ladelund received funding from Novo Nordisk. Dr. Eugen-Olsen is a co-founder, shareholder, and Chief Scientific Officer (currently) of ViroGates A/S. Drs. Eugen-Olsen and Andersen are named inventors on patents on soluble urokinase plasminogen activator receptor as a prognostic biomarker; the patents are owned by Copenhagen University Hospital Amager and Hvidovre, Denmark, and licensed to ViroGates A/S. Dr. Ellekilde disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: line.jee.hartmann.rasmussen@regionh.dk Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: EOLIA and Beyond

No abstract available

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Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration

Objectives: Previous studies have looked at National Early Warning Score performance in predicting in-hospital deterioration and death, but data are lacking with respect to patient outcomes following implementation of National Early Warning Score. We sought to determine the effectiveness of National Early Warning Score implementation on predicting and preventing patient deterioration in a clinical setting. Design: Retrospective cohort study. Setting: Tertiary care academic facility and a community hospital. Patients: Patients 18 years old or older hospitalized from March 1, 2014, to February 28, 2015, during preimplementation of National Early Warning Score to August 1, 2015, to July 31, 2016, after National Early Warning Score was implemented. Interventions: Implementation of National Early Warning Score within the electronic health record and associated best practice alert. Measurements and Main Results: In this study of 85,322 patients (42,402 patients pre-National Early Warning Score and 42,920 patients post-National Early Warning Score implementation), the primary outcome of rate of ICU transfer or death did not change after National Early Warning Score implementation, with adjusted hazard ratio of 0.94 (0.84–1.05) and 0.90 (0.77–1.05) at our academic and community hospital, respectively. In total, 175,357 best practice advisories fired during the study period, with the best practice advisory performing better at the community hospital than the academic at predicting an event within 12 hours 7.4% versus 2.2% of the time, respectively. Retraining National Early Warning Score with newly generated hospital-specific coefficients improved model performance. Conclusions: At both our academic and community hospital, National Early Warning Score had poor performance characteristics and was generally ignored by frontline nursing staff. As a result, National Early Warning Score implementation had no appreciable impact on defined clinical outcomes. Refitting of the model using site-specific data improved performance and supports validating predictive models on local data. Drs. O’Brien and Goldstein are co-senior authors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/29S62lw). Supported, in part, by grants from National Institute of Diabetes and Digestive and Kidney Diseases & Allergy and Infectious Diseases; Health and Human Services (HHS)|National Institutes of Health (NIH)|National Institute of Allergy and Infectious Diseases: T32-AI007392 (to Dr. Clement); HHS|NIH|National Institute of Diabetes and Digestive and Kidney Diseases: K25-DK097279 and Duke Center for Integrative Health (to Dr. Goldstein); and Duke Center for Integrative Health (to Drs. Steorts and O’Brien). The funding bodies had no role in the study’s design, conduct, review, or reporting or the decision to submit the article for publication. Drs. Bedoya, Clement, and Goldstein received support for article research from the National Institutes of Health. Dr. Clement received funding from UpToDate (royalties). Dr. Steorts received funding from employment with U.S. Census Bureau; she holds an National Science Foundation (NSF) Career grant and NSF privacy grant (both not related to this study); and she received support for article research from a seed grant from Duke University. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: armando.bedoya@duke.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Is the number of rib fractures a risk factor for delayed complications? A case–control study

Abstract

Aim

To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications.

Method

Retrospective case–control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage.

Results

One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients’ baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11).

Conclusions

The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

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Decision making and mental health in EMS

Recognizing three common patient care decisions that contribute to cumulative stress on EMS providers

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Firefighter training can be fun and serious at the same time

By taking an innovative and creative approach, training drills can maintain their educational value while also adding an element of fun

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Periurethral Abscess Complicating Urethral Diverticulum

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Michael D. Zwank

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Sudden Cardiac Arrest Due to Hemophagocytic Lymphohistiocytosis in a Child

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Michael C. McCrory, Sophia S. Wang, Avinash K. Shetty, Thomas W. McLean, Patrick E. Lantz, Michael L. Cannon

Abstract

Background

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation.

Case Report

A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death.

Why Should an Emergency Physician be Aware of This?

HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

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Bye Bye Biceps: Case Report Describing Presentation, Physical Examination, Diagnostic Workup, and Treatment of Acute Distal Biceps Brachii Tendon Rupture

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Nicholas Pflederer, Zacharias Zitterkopf, Shailendra Saxena

Abstract

Background

Rupture of the distal biceps tendon is seen in both the emergency and primary care settings. It most commonly occurs after excessive tension exerted on a flexed forearm. Knowledge of the anatomy, pathophysiology, historical and physical examination findings, as well as the workup, diagnosis, and treatment of distal biceps tendon rupture are essential in achieving good outcomes, as delays in treatment can make surgical repair more challenging and less efficacious.

Case Report

A healthy 38-year-old male presented to his primary care physician complaining of right elbow pain that started while lifting an all-terrain vehicle into a truck. On physical examination, the patient had obvious deformity of the distal upper arm, as well as a positive squeeze test. Magnetic resonance imaging confirmed the presence of complete rupture of the distal biceps brachii tendon and the patient was referred to orthopedic surgery for evaluation.

Why Should an Emergency Physician Be Aware of This?

Prompt diagnosis and referral to orthopedic surgery optimizes outcomes and minimizes complications after distal biceps brachii tendon rupture. Oftentimes, gross examination shows obvious deformity of the distal upper arm, but when swelling, mobility limitations, or patient anatomy hinder this physical examination finding, the diagnosis can be missed. Knowledgeable emergency physicians can perform a physical examination and other diagnostic tests that can confirm or rule out a diagnosis in order to achieve the best outcomes for patients.

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Elevated Optic Disc Height and Increased Optic Nerve Sheath Diameter on Bedside Ultrasound in a Pediatric Patient With Orbital Cellulitis: More Than Meets the Eye

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Vigil James, Gene Yong-Kwang Ong

Abstract

Background

Orbital cellulitis is an uncommon ophthalmological emergency in children, but rapid emergency department (ED) diagnosis is essential.

Case Report

A 13-year-old boy presented to our pediatric ED with left orbital cellulitis secondary to pansinusitis. Emergency bedside ocular ultrasonography was used to evaluate and expedite his management. Besides inflammatory changes observed on ultrasound of his affected orbit, the patient had an elevated optic disc height and increased nerve sheath diameter, which were not commonly reported in published literature on orbital cellulitis. Emergent computed tomography of the orbits and head showed orbital cellulitis without complications of orbital abscess or cavernous sinus thrombosis. Despite initiating early appropriate antibiotics, there was rapid progression of his disease and he developed intraconal abscess and cavernous sinus thrombosis the following day. After emergency surgical drainage of his pansinusitis, antibiotics, and anticoagulation, he was discharged well after a 2-week hospitalization.

Why Should an Emergency Physician Be Aware of This?

There are important advantages of using bedside ultrasonography for diagnosis of pediatric orbital cellulitis in the ED setting. Further research should be done to evaluate the clinical significance of an enlarged optic nerve sheath diameter and raised optic disc height in pediatric orbital cellulitis.

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Sepsis Core Measures – Are They Worth the Cost?

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Amanda Esposito, Michael E. Silverman, Frank Diaz, Frederick Fiesseler, Gita Magnes, David Salo

Abstract

Background

In 2015, the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission launched the sepsis core measures in an attempt to decrease sepsis morbidity and mortality. Recent studies call into question the multiple treatment measures in early goal-directed therapy on which these CMS measures are based.

Objectives

The purpose of this study is to compare the utilization of resources due to the implementation of the sepsis core measures while examining whether complying with these treatment guidelines decreases patient mortality.

Methods

Data were collected on patients suspected of sepsis in a suburban academic emergency department. These data were collected over the course of 3 consecutive years. The data collected included lactates, blood cultures, and antibiotics (vancomycin, piperacillin/tazobactam) ordered. The mortality rate of patients with a final diagnosis of sepsis present on arrival was calculated for a 3-month period of each year and compared.

Results

There was no difference in the mortality rates of patients with sepsis across the 3 years. There was an increase in the amount of piperacillin/tazobactam and vancomycin administered. There was a significant increase in the number of lactates and blood cultures ordered per patient across all 3 years.

Conclusions

There was no difference in the mortality rate of patients with a final diagnosis of sepsis. However, there was a significant increase in the utilization of resources to care for these patients. As a result of the overutilization of these resources, the cost for both patients and hospitals has increased without improvement in mortality.

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Prevalence of Emergency Department Patients Presenting with Heroin or Prescription Opioid Abuse Residing in Urban, Suburban, and Rural Jefferson County

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Kiran A. Faryar, Thomas I. Ems, Bikash Bhandari, Martin R. Huecker

Abstract

Background

Heroin and prescription opioid abuse in the United States is exhibiting a growing geographic ubiquity.

Objectives

This study characterizes the changing geographic distribution of patients presenting with heroin and prescription opioid abuse to one urban emergency department (ED).

Methods

A retrospective review of patients with heroin and prescription opioid abuse from 2009–2014 was conducted in one adult urban ED. The primary outcome was the prevalence of heroin and prescription opioid patients residing in urban, suburban, and rural ZIP codes over time.

Results

From 2009 to 2014, 2695 patients presented for either heroin (N = 1436; 53%) or prescription opioid (N = 1259; 47%) abuse from 32 Jefferson County ZIP codes. Of the 32 ZIP codes, 15 were urban (47%), 13 suburban (41%), and 4 rural (12%). The prevalence of heroin patients (per 10,000 population) increased in each ZIP code from 2009–2014. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but increased in rural ones. Using segmented regression analysis, the increase in patients who used heroin residing in all ZIP codes and the decrease in patients abusing prescription opioids residing in urban areas was statistically significant after 2011.

Conclusion

From 2009 to 2014, there was an increasing trend in ED patients using heroin who resided in urban, suburban, and rural ZIP codes. There was an increasing trend in prescription opioid prevalence in all regions from 2009 to 2011. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but not rural ZIP codes.

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Traffic Intensity of Patients and Physicians in the Emergency Department: A Queueing Approach for Physician Utilization

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Chung-Hsien Chaou, Hsiu-Hsi Chen, Petrus Tang, Amy Ming-Fang Yen, Kuan-Han Wu, Cheng-Ting Hsiao, Te-Fa Chiu

Abstract

Background

The unpredictable nature of patient visits poses considerable challenges to the staffing of emergency department (ED) medical personnel. There is a lack of common physician usage parameters at present.

Objective

The aim of this study was to quantify the ED traffic intensity of patients and physicians using a queueing model approach.

Methods

A retrospective administrative electronic data analysis was conducted in a tertiary medical center. All patients who registered at the ED in 2013 were included. Precisely recorded patient waiting time, service time, and disposition time were obtained. An M/M/s (Markovian patient arrival, Markovian patient service, s servers) queueing model was used, while taking account of the actual physician number and number of patients managed simultaneously. Physician utilization and performance indicators were measured.

Results

A total of 148,581 patients were analyzed after exclusion. The overall mean waiting time, service time, and disposition time were 0.23 (standard deviation [SD] = 0.24), 2.31 (SD = 3.89), and 2.54 (SD = 3.90) hours, respectively. Hourly physician utilization (ρ), stratified by different patient entities, was ρ = 0.75 ± 0.17 for adult non-trauma, ρ = 0.75 ± 0.28 for pediatric, and ρ = 0.53 ± 0.18 for trauma (p = 0.0004). There was a surge of utility for pediatric non-trauma patients in the late evening (ρ = 1.4 at 11 pm). The distribution of number of patients in the system was derived and compared by different patient entities and time points.

Conclusions

A queueing model was built to model traffic intensity of physicians and patients, the physician utility trend disclosed the fluctuation of manpower utility. The estimated parameters serve as important factors for developing tailored staffing policies for minimizing ED waiting and improving ED crowding.

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A Description of a Health System's Emergency Department Patients Who Were Part of a Large Hepatitis A Outbreak

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Allyson A. Kreshak, Jesse J. Brennan, Gary M. Vilke, Vaishal M. Tolia, Max Caccese, Edward M. Castillo, Theodore C. Chan

Abstract

Background

A recent hepatitis A virus (HAV) outbreak in San Diego, California represents one of the largest HAV outbreaks in the United States. The County of San Diego Health and Human Services Agency identified homelessness and illicit or injection drug use as risk factors for contracting HAV during this outbreak.

Objective

We describe those patients who presented to our Emergency Department (ED) and were identified as HAV positive.

Methods

This was a retrospective descriptive study conducted at a tertiary care university health system's EDs from November 2016 to February 2018. Included were those of all ages who tested positive for HAV immunoglobulin M antibody. Outcome measures included: 1) demographic data; 2) number of patients testing positive for HAV by week and month of the outbreak; 3) homeless status, illicit and injection drug use, and alcohol use; 4) ED chief complaint; 5) initial liver function and coagulopathy test results, hepatitis B and C test results, and initial vital signs; 6) admission status; 7) death; and 8) the 7-day ED revisit rate for nonadmitted patients and the 30-day all-cause readmission rate for admitted patients.

Results

We identified 57,721 patients with at least one ED visit, and 1,453 of these were tested for HAV; 133 patients (9.2%) tested positive. Average age was 45.1 years, and 91 (68.4%) were male. Eighty-six patients (64.7%) were homeless and 53 patients (39.8%) reported illicit or injection drug use; 64 patients (48.1%) had chief complaints consistent with typical HAV symptoms. Most patients (112 or 84.2%) were admitted. Nine patients (6.8%) were admitted to a critical care setting; 8 patients (6%) died.

Conclusions

During this large HAV outbreak, 9% of those screened for HAV tested positive. The majority were homeless, and 40% reported illicit or injection drug use. Most required hospitalization, and 6% of patients died.

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Emergent Complications of Rheumatoid Arthritis

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Samantha Berman, Joshua Bucher, Alex Koyfman, Brit J. Long

Abstract

Background

Rheumatoid arthritis (RA) is an autoimmune disease resulting in polyarthritis and systemic effects that may result in morbidity and mortality.

Objective

This review provides the emergency physician with an updated analysis of acute complications seen with RA, as well as an evidence-based approach to the management of these complications.

Discussion

While the joint characteristics of RA are commonly recognized, the extra-articular manifestations may be overlooked. Of most concern to the emergency clinician is the involvement of the airway, cardiovascular, and pulmonary systems; however, RA can affect all organ systems. In addition, complications can arise from the specific therapies used to treat RA. Certain patient populations can have atypical presentations of the disease or may have an exaggerated response to the medications. An understanding of the involvement of these organ systems and complications can direct physicians to a broader differential that can identify disease processes that may have otherwise gone unnoticed. It is not necessarily the role of the clinician to diagnose RA in its earliest phases or initiate long-term immunosuppressive therapy from the emergency department; however, detection of some of the disease's characteristics can lead to earlier referral to specialists to begin therapy and potentially avoid life-threatening complications. If those problems are encountered in the emergency department, this review aims to provide insight into management of those conditions.

Conclusions

Prompt recognition of the acute complications of RA is crucial to treat these conditions. This review investigates these issues in a succinct manner for emergency clinicians.

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Unusual Complications From Babesia Infection: Splenic Infarction and Splenic Rupture in Two Separate Patients

Publication date: Available online 22 September 2018

Source: The Journal of Emergency Medicine

Author(s): Benjamin Blackwood, William Binder

Abstract

Background

Babesiosis is a zoonotic parasitic infection transmitted by the tick, Ixodes scapularis. Splenic infarct and rupture are infrequent complications of Babesia parasitemia, and have not been previously reported in the emergency medicine literature.

Case Report

We present two separate cases seen within 1 month at our institution: a case of splenic rupture and another case of splenic infarction due to Babesia parasitemia.

Why Should an Emergency Physician Be Aware of This?

Babesia infection in humans is increasingly prevalent in both the United States and worldwide, and clinical manifestations can range from subclinical to fulminant infections. An unusual but potentially fatal complication of babesiosis is splenic infarctions and rupture. Due to the endemicity of this parasite, a careful history and level of suspicion will enable the emergency physician to consider and test for babesiosis in patients with splenic injuries and without obvious traditional risk factors.

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