Showing papers in "American Journal of Emergency Medicine in 2013"
TL;DR: In this article, the diagnostic performance of chest X-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients was evaluated.
Abstract: Objective
To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients.
248 citations
TL;DR: Red cell distribution width was significantly higher in nonsurvivors than in survivors, and the corresponding mortality of patients with an RDW of 14% or less, 14.1% to 15.7%, and 15.8% or greater was 13.1%, 30.1, and 44.9%, respectively.
Abstract: Objective This study was performed to investigate the association of red cell distribution width (RDW) with 28-day mortality in patients with severe sepsis and septic shock. Methods We performed a retrospective analysis of patients with severe sepsis and septic shock. Patients' demographic data, comorbidities, the blood test results including RDW at admission to the emergency department, and Acute Physiologic and Chronic Health Evaluation II score were compared between 28-day survivors and nonsurvivors. Red cell distribution width was categorized into tertiles as 14% or less, 14.1% to 15.7%, and 15.8% or greater. Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality. Results A total of 566 patients were included, and overall mortality was 29%. Red cell distribution width was significantly higher in nonsurvivors than in survivors, and the corresponding mortality of patients with an RDW of 14% or less, 14.1% to 15.7%, and 15.8% or greater was 13.1%, 30.1%, and 44.9%, respectively ( P Conclusion Red cell distribution width is associated with 28-day mortality in patients with severe sepsis and septic shock.
162 citations
TL;DR: The objective was to describe the incidence of violence in ED health care workers (HCWs) over 9 months and identify demographic, occupational, and perpetrator factors related to violent events (VEs) and identify predictors of acute stress in victims and predictor of loss of productivity.
Abstract: Background Health care support occupations have an assault-injury rate nearly 10 times the general sector. Emergency departments (EDs) are at greatest risk of such events. Objective The objective was to describe the incidence of violence in ED health care workers (HCWs) over 9 months. Specific aims were to (1) identify demographic, occupational, and perpetrator factors related to violent events (VEs) and (2) identify predictors of acute stress in victims and predictors of loss of productivity. Methods A longitudinal, repeated-methods design was used to collect monthly survey data from ED HCWs at 6 hospitals. Surveys assessed number and type of VEs, and feelings of safety and confidence. Victims also completed specific VE surveys. Descriptive statistics and a repeated-measure linear regression model were used. Results Two hundred thirteen ED HCWs completed 1795 monthly surveys and 827 VEs were reported. Average VE rate per person per 9 months was 4.15. Six hundred one events were physical threats (PTs) (3.01 per person). Two hundred twenty six events were assaults (1.13 per person). Five hundred one VE surveys were completed, describing 341 PTs and 160 assaults. Men perpetrated 63% of PTs and 52% of assaults. Significant differences in VEs were reported between registered nurses (RNs) and medical doctors (MDs) ( P = .0017) and patient care assistants ( P P = .0041). The MDs felt more confident than the RNs in dealing with violent patients ( P = .013). The RNs were more likely to experience acute stress than the MDs ( P P Conclusion Emergency department HCWs are frequent victims of violence perpetrated by visitors and patients. This results in injuries, acute stress, and lost productivity. Acute stress has negative consequences on workers' ability to perform their duties.
155 citations
TL;DR: The sonographic diameter of the optic nerve sheath might be considered a strong and accurate predicting factor for increased intracranial pressure.
Abstract: Background and aims An increase in the intracranial pressure (ICP) might aggravate patient outcomes by inducing neurologic injuries. In patients with increased ICP the optic nerve sheath diameter (ONSD) increases due to its close association with the flow of cerebrospinal fluid. The present study was an attempt to evaluate the efficacy of sonographic ONSD in estimating ICP of patients who are candidates for lumbar puncture (LP). Materials and methods In this descriptive prospective study, the ONSD was measured before LP using an ultrasonography in 50 nontraumatized patients who were candidates for LP due to varies diagnoses. Immediately after the sonography, the ICP of each patient was measured by LP. Correlation tests were used to evaluate the relationship between ICP and the sonographic diameter of the optic nerve sheath. Receiver operating characteristic curve was used to find the optimal cut-off point in order to diagnose ICP values higher than 20 cm H 2 O. Results The means of the ONSD were 5.17 ± 1.01 and 5.19 ± 1.06 mm on the left and right sides, respectively ( P = .552). The mean ONSD for the patients with increased ICP and normal individuals were 6.66 ± 0.58 and 4.60 ± 0.41 mm, respectively ( P P r = 0.88). The ONSD of greater than 5.5 mm predicted an ICP of ≥20 cm H 2 O with sensitivity and specificity of 100% (95% CI, 100-100) ( P Conclusion The sonographic diameter of the optic nerve sheath might be considered a strong and accurate predicting factor for increased intracranial pressure.
146 citations
TL;DR: In this article, the authors evaluated physician productivity using electronic medical records in a community hospital emergency department and found that physicians spend significantly more time entering data into electronic medical record than on any other activity, including direct patient care.
Abstract: Objective We evaluate physician productivity using electronic medical records in a community hospital emergency department. Methods Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records. Results The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift. Conclusion Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.
129 citations
TL;DR: In this study, US was 100% specific for the diagnosis of acutely decompensated heart failure among acutely dyspneic patients in the ED.
Abstract: Background Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. Methods This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. Results One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). Conclusion In this study, US was 100% specific for the dx of ADHF.
120 citations
TL;DR: Estimating the receiver operating characteristic area under the curve showed that RDW has very good discriminative power for mortality, and is a predictor of mortality in patients with AP.
Abstract: Introduction Acute pancreatitis (AP) is a common cause for hospitalization worldwide. Identification of patients at risk for mortality early in the course of AP is an important step in improving outcome. Red cell distribution width (RDW) is reflective of systemic inflammation. The objective of this study was to investigate the association between RDW and mortality in patients with AP. Methods A total of 102 patients with AP were included. Demographic data, etiology of pancreatitis, organ failure, metabolic disorder, hospitalization time, and laboratory measures including RDW were obtained from each patient on admission. Results Estimating the receiver operating characteristic area under the curve showed that RDW has very good discriminative power for mortality (area under the curve = 0.817; 95% confidence interval, 0.689-0.946). With a cutoff value of 14.8 for RDW, mortality could be correctly predicted in approximately 77% of cases. Conclusions Red cell distribution width on admission is a predictor of mortality in patients with AP.
115 citations
TL;DR: Bedside serial measurements of dIVC and dRV could be a useful noninvasive tool for the detection and follow-up of patients with hypovolemia and evaluation of the response to the treatment.
Abstract: Objective Ultrasonography has been suggested as a useful noninvasive tool for the detection and follow-up for hypovolemia. Two possible sonographic markers as a surrogate for hypovolemia are the diameters of the inferior vena cava (dIVC) and the right ventricle (dRV). The goal of this study was to evaluate IVC and RV diameters and diameter changes in patients treated for hypovolemia and compare these findings with healthy volunteers. Methods Fifty healthy volunteers and 50 consecutive hypovolemic patients were enrolled in the study. The dIVC, both during inspiration (IVCi) and expiration (IVCe), was measured in hypovolemic patients both before and after fluid resuscitation, and they were also measured in healthy volunteers during the time they participated in the study. The dIVC, in hypovolemic patients both before and after fluid resuscitation, was measured ultrasonographically by M-mode in the subxiphoid area. The dRV was measured ultrasonographically by B-mode in the third and fourth intercostals spaces. Results The average diameters of the IVCe, IVCi, and dRV in hypovolemic patients upon arrival were significantly lower compared with healthy volunteers ( P = .001). After fluid resuscitation, there was a significant increase in the mean diameters of the IVCe, IVCi, and RV in hypovolemic patients ( P = .001). Conclusions The results indicate that the dIVC and dRV are consistently low in hypovolemic subjects when compared with euvolemic subjects. Bedside serial measurements of dIVC and dRV could be a useful noninvasive tool for the detection and follow-up of patients with hypovolemia and evaluation of the response to the treatment.
100 citations
TL;DR: Red cell distribution width was associated with 30-day mortality, length of hospital stay, and use of vasopressors in hospitalized patients with CAP, and the inclusion of RDW improved the prognostic performance of the PSI and CURB-65.
Abstract: Background Red cell distribution width (RDW) is associated with mortality in both the general population and in patients with certain diseases. However, the relationship between RDW and mortality in patients with community-acquired pneumonia (CAP) is unknown. The objective of this study was to evaluate the association of RDW with mortality in patients with CAP. Methods We performed a retrospective analysis of a prospective registry database of patients with CAP. Red cell distribution width was organized into quartiles. The pneumonia severity index (PSI) and CURB-65 were calculated. The primary outcome was 30-day mortality. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, vasopressor use, and the need for mechanical ventilation. Results A total of 744 patients were included. The PSI and CURB-65 were higher in patients with a high RDW. Multivariate logistic regression analysis identified higher categories of RDW, PSI, CURB-65, and albumin as statistically significant variables. Thirty-day mortality was significantly higher in patients with a higher RDW. Among the secondary outcomes, the length of hospital stay and vasopressor use were significantly different between the groups. In a Cox proportional hazard regression analysis, patients with higher categories of RDW exhibited increased mortality before and after adjustment of the severity scales. Receiver operating characteristics curves demonstrated improved mortality prediction when RDW was added to the PSI or CURB-65. Conclusion Red cell distribution width was associated with 30-day mortality, length of hospital stay, and use of vasopressors in hospitalized patients with CAP. The inclusion of RDW improved the prognostic performance of the PSI and CURB-65.
100 citations
TL;DR: The African-American race of the SCD patients, and their status as having SCD itself, both appear to contribute to longer wait times for these patients, which confirm patient anecdotal reports and are in need of intervention.
Abstract: Study objective To determine whether patients with sickle cell disease (SCD) experience longer wait times to see a physician after arrival to an emergency department (ED) compared to patients with long bone fracture and patients presenting with all other possible conditions (General Patient Sample), and to attempt to disentangle the effects of race and disease status on any observed differences. Methods A cross-sectional, comparative analysis of year 2003 through 2008 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of nonfederal emergency department visits in the United States. Our primary outcome was wait time (in minutes) to see a physician after arrival to an ED. A generalized linear model was used to examine ratios of wait times comparing SCD visits to the two comparison groups. Results SCD patients experienced wait times 25% longer than the General Patient Sample, though this difference was explained by the African-American race of the SCD patients. SCD patients waited 50% longer than did patients with long bone fracture even after accounting for race and assigned triage priority. Conclusions Patients with SCD presenting to an ED for care experience longer wait times than other groups, even after accounting for assigned triage level. The African-American race of the SCD patients, and their status as having SCD itself, both appear to contribute to longer wait times for these patients. These data confirm patient anecdotal reports and are in need of intervention.
99 citations
TL;DR: During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared to manual chest-compressions increased CPR quality and reduced hands-off time, but prolonged the time interval to the first defibrillation.
Abstract: Objective High-quality chest-compressions are of paramount importance for survival and good neurological outcome after cardiac arrest. However, even healthcare professionals have difficulty performing effective chest-compressions, and quality may be further reduced during transport. We compared a mechanical chest-compression device (Lund University Cardiac Assist System [LUCAS]; Jolife, Lund, Sweden) and manual chest-compressions in a simulated cardiopulmonary resuscitation scenario during helicopter rescue. Methods Twenty-five advanced life support–certified paramedics were enrolled for this prospective, randomized, crossover study. A modified Resusci Anne manikin was employed. Thirty minutes of training was allotted to both LUCAS and manual cardiopulmonary resuscitation (CPR). Thereafter, every candidate performed the same scenario twice, once with LUCAS and once with manual CPR. The primary outcome measure was the percentage of correct chest-compressions relative to total chest-compressions. Results LUCAS compared to manual chest-compressions were more frequently correct (99% vs 59%, P P P P = .001). Hands-off time was shorter in the LUCAS than in the manual group (46 vs 130 seconds, P P Conclusions During this simulated cardiac arrest scenario in helicopter rescue LUCAS compared to manual chest-compressions increased CPR quality and reduced hands-off time, but prolonged the time interval to the first defibrillation. Further clinical trials are warranted to confirm potential benefits of LUCAS CPR in helicopter rescue.
TL;DR: Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis in a randomized clinical trial.
Abstract: Objective Epistaxis is a common problem in the emergency department (ED). Sixty percent of people experience it at least once in their life. There are different kinds of treatment for epistaxis. This study intended to evaluate the topical use of injectable form of tranexamic acid vs anterior nasal packing with pledgets coated with tetracycline ointment. Methods Topical application of injectable form of tranexamic acid (500 mg in 5 mL) was compared with anterior nasal packing in 216 patients with anterior epistaxis presented to an ED in a randomized clinical trial. The time needed to arrest initial bleeding, hours needed to stay in hospital, and any rebleeding during 24 hours and 1 week later were recorded, and finally, the patient satisfaction was rated by a 0-10 scale. Results Within 10 minutes of treatment, bleedings were arrested in 71% of the patients in the tranexamic acid group, compared with 31.2% in the anterior nasal packing group (odds ratio, 2.28; 95% confidence interval, 1.68-3.09; P Conclusions Topical application of injectable form of tranexamic acid was better than anterior nasal packing in the initial treatment of idiopathic anterior epistaxis.
TL;DR: A case is presented that was intentionally treated with substantial amounts of omega-3 fatty acids (n-3FA) to provide the nutritional foundation for the brain to begin the healing process following severe TBI.
Abstract: Traumatic brain injury (TBI) has long been recognized as the leading cause of traumatic death and disability. Tremendous advances in surgical and intensive care unit management of the primary injury, including maintaining adequate oxygenation, controlling intracranial pressure, and ensuring proper cerebral perfusion pressure, have resulted in reduced mortality. However, the secondary injury phase of TBI is a prolonged pathogenic process characterized by neuroinflammation, excitatory amino acids, free radicals, and ion imbalance. There are no approved therapies to directly address these underlying processes. Here, we present a case that was intentionally treated with substantial amounts of omega-3 fatty acids (n-3FA) to provide the nutritional foundation for the brain to begin the healing process following severe TBI. Recent animal research supports the use of n-3FA, and clinical experience suggests that benefits may be possible from substantially and aggressively adding n-3FA to optimize the nutritional foundation of severe TBI patients and must be in place if the brain is to be given the opportunity to repair itself to the best possible extent. Administration early in the course of treatment, in the emergency department or sooner, has the potential to improve outcomes from this potentially devastating public health problem.
TL;DR: Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management, as determined by a trauma expert panel.
Abstract: Background Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant. Study Objectives This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. Methods Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance. Results Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries—primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT. Conclusion Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management.
TL;DR: Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses.
Abstract: Study objective To determine whether frequent emergency department (ED) users are more likely to make at least one and a majority of visits for mental health, alcohol, or drug-related complaints compared to non-frequent users. Methods We performed a retrospective cohort study exploring frequent ED use and ED diagnosis at a single, academic hospital and included all ED patients between January 1 and December 31, 2010. We compared differences in ED visits with a primary International Classification of Diseases, 9th Revision visit diagnosis of mental health, alcohol or drug-related diagnoses between non-frequent users ( Results Frequent users (2496/65201 [3.8%] patients) were more likely to make at least one visit associated with mental health, alcohol, or drug-related diagnoses. The proportion of patients with a majority of visits related to any of the three diagnoses increased from 5.8% among non-frequent users (3616/62705) to 9.4% among repeat users (181/1926), 13.1% among highly frequent users (62/473), and 25.8% (25/97 patients) in super frequent users. An increasing proportion of visits with alcohol-related diagnoses was observed among repeat, highly frequent, and super frequent users but was not found for mental health or drug-related complaints. Conclusion Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses. To address frequent ED use, interventions focusing on managing patients with frequent alcohol-related visits may be necessary.
TL;DR: A case of CHS is reported that improved significantly after treatment with haloperidol in the emergency department, and patients often require hospital admission.
Abstract: Cannabinoid hyperemesis syndrome (CHS) is a condition characterized by cyclical vomiting without other identifiable cause in patients with chronic cannabis use. Patients with CHS report that compulsive bathing and hot showers are the only reliable treatments to improve symptoms. Cannabinoid hyperemesis syndrome is usually unresponsive to conventional pharmacologic antiemetics, and patients often require hospital admission. We report a case of CHS that improved significantly after treatment with haloperidol in the emergency department.
TL;DR: MR-proADM may be helpful in individual risk stratification of CAP patients with a high PSI score in the ED, allowing to a better identification of patients at risk of death.
Abstract: The aim of the present study was, first, to evaluate the prognostic value of mid-regional proadrenomedullin (proADM) in emergency department (ED) patients with a diagnosis of community acquired pneumonia (CAP) and, second, to analyze the added value of proADM as a risk stratification tool in comparison with other biomarkers and clinical severity scores. We evaluated proADM, C-reactive protein and procalcitonin, along with the Pneumonia Severity Index (PSI) score in consecutive CAP patients. Ability to predict 30-day mortality was assessed using receiver operating characteristic curve analysis, logistic regression, and reclassification metrics for all patients and for patients with high PSI scores. Primary outcome was death within 30 days after ED admission. One hundred nine patients were included (median age [interquartile range] 71 [27] years). Nine patients died within 30 days. A significant correlation between proADM and PSI was found ( ρ = 0.584, P 90), proADM levels significantly predicted risk of death (OR [95% CI], 4.681 (1.661-20.221), P = .012) whereas PSI score did not ( P = .122). ROC AUC (area under the receiver operating characteristic curve) was higher for proADM than for PSI score (ROC AUC [95% CI], 0.810 [0.654-0.965] and 0.669 [0.445-0.893] respectively). Reclassification analysis revealed that combination of PSI and proADM allows a better risk assessment than PSI alone ( P = .001). MR-proADM may be helpful in individual risk stratification of CAP patients with a high PSI score in the ED, allowing to a better identification of patients at risk of death.
TL;DR: The GBS can be used to predict need for intervention and transfusion in patients with UGIB in the authors' ED, whereas full RS can be successfully used to stratify the mortality risk in these patients.
Abstract: Background Admission Rockall score (RS), full RS, and Glasgow-Blatchford Bleeding Score (GBS) can all be used to stratify the risk in patients presenting with upper gastrointestinal bleeding (UGIB) in the emergency department (ED). The aim of our study was to compare both admission and full RS and GBS in predicting outcomes at UGIB patients in a Romanian ED. Patients and Methods A total of 229 consecutive patients with UGIB were enrolled in the study. Patients were followed up 60 days after admission to ED because of UGIB episode to determine cases of rebleeding or death during this period. By using areas under the curve (AUCs), we compared the 3 scores in terms of identifying the most predictive score of unfavorable outcomes. Results Rebleeding rate was 40.2% (92 patients), and mortality rate was 18.7% (43 patients). For the prediction of mortality, full RS was superior to GBS (AUC, 0.825 vs 0.723; P = .05) and similar to admission RS (AUC, 0.792). Glasgow-Blatchford Bleeding Score had the highest accuracy in detecting patients who needed transfusion (AUC, 0.888) and was superior to both the admission RS and full RS (AUC, 0.693 and 0.750, respectively) ( P P P = .04, respectively). Conclusions The GBS can be used to predict need for intervention and transfusion in patients with UGIB in our ED, whereas full RS can be successfully used to stratify the mortality risk in these patients.
TL;DR: Renal impairment was not observed in any of the patients who experienced apnea and the prevalence of and predisposing factors for tramadol-related apnea in patients referred to Loghman-Hakim Hospital was determined.
Abstract: Background and Objectives In contrast with other opioids, there are few cases of tramadol-related respiratory depression described in the literature, and renal impairment is a proposed risk factor. The aim of this study is to determine the prevalence of and predisposing factors for tramadol-related apnea in patients referred to our center. Patients and Methods All patients referred to Loghman-Hakim Hospital between February 2009 and April 2010 with pure tramadol intoxication were identified retrospectively. Data collected included the patient's age, sex, ingested dose, route of exposure, reason for poisoning (acute overdose or supratherapeutic use), previous history of suicidal attempts, previous history of drug or substance abuse (including tramadol), and clinical features on admission including seizures and apnea. Results We identified 525 patients with deliberate self-poisoning (359; 68.4%) or abuse (146; 27.8%), and in 114 (21.7%) of these, there was a history of tramadol abuse. Four hundred twenty-nine (81.7%) of patients had acute poisoning and were referred to hospital within 6 hours of ingestion. Nineteen patients (3.6%) experienced apnea and received respiratory support (16; 84.2%) or naloxone administration (3; 15.8%) within 24 hours of ingestion (mean, 7.7 ± 7 hours; range, 1-24 hours). The mean dose ingested by patients experiencing apnea was 2125 ± 1360 mg (range, 200-4600 mg), which was significantly higher than those who did not experience apnea, 1383 ± 1088 mg (range, 100-6000 mg), P P
TL;DR: Interaction terms suggest the association between elder abuse and ED utilization is not mediated through medical comorbidities, cognitive and functional impairment, or psychosocial distress.
Abstract: Purpose This study aims to quantify the relationship between overall elder abuse and specific subtypes of elder abuse and rate of emergency department (ED) utilization in a community-dwelling population. Methods A population-based study is conducted in Chicago of community-dwelling older adults who participated in the Chicago Health and Aging Project. Of the 6674 participants in the Chicago Health and Aging Project, 106 participants were reported to a social services agency for suspected elder abuse. The primary predictor was elder abuse reported to a social services agency. The outcome of interest was the annual rate of ED utilization obtained from the Center for Medicare and Medicaid Services. Poisson regression models were used to assess these longitudinal relationships. Results The average annual rate of ED visits for those without elder abuse was 0.7(1.4) and, for those with reported elder abuse, was 2.1(3.2). After adjusting for sociodemographics, socioeconomic variables, medical comorbidities, cognitive and physical function, and psychosocial wellbeing, older adults who have been abused had higher rates of ED utilization (RR, 2.33 [1.60-3.38]). Psychological abuse (RR, 1.98[1.29-3.00]), financial exploitation (RR, 1.59 [1.01-2.52]) and caregiver neglect (RR, 2.04 [1.38-2.99]) were associated with increased rates of ED utilization, after considering the same confounders. Interaction terms suggest the association between elder abuse and ED utilization is not mediated through medical comorbidities, cognitive and functional impairment, or psychosocial distress. Conclusion Elder abuse was associated with increased rates of ED utilization in this community population. Specific subtypes of elder abuse had differential association with increased rate of ED utilization.
TL;DR: One out of 8 Medicaid enrollees who visited the ED had ≥4 visits in a year, and patients with ≥18 visits per year were more likely to be homeless and suffer from alcohol abuse.
Abstract: Background Medicaid enrollees are disproportionately represented among patients with frequent Emergency Department (ED) visits, yet prior studies investigating frequent ED users have focused on patients with all insurance types. Methods This was a single center, retrospective study of Medicaid-insured frequent ED users (defined as ≥4 ED visits/year not resulting in hospital admission) to assess patients' sociodemographic and clinical characteristics and evaluate differences in these characteristics by frequency of use (4-6, 7-17, and ≥18 ED visits). Results Twelve percent (n = 1619) of Medicaid enrollees who visited the ED during the 1-year study period were frequent ED users, accounting for 38% of all ED visits (n = 10,337). Most frequent ED users (n = 1165, 72%) had 4-6 visits; 416 (26%) had 7-17 visits, and 38 (2%) had ≥18 visits. Overall, 67% had a primary care provider and 56% had at least one chronic medical condition. The most common ED diagnosis among patients with 4-6 visits was abdominal pain (7%); among patients with 7-17 and ≥18 ED visits, the most common diagnosis was alcohol-related disorders (11% and 36%, respectively). Compared with those who had 4-6 visits, patients with ≥18 visits were more likely to be homeless (7% vs 42%, P P Conclusion One out of 8 Medicaid enrollees who visited the ED had ≥4 visits in a year. Efforts to reduce frequent ED use should focus on reducing barriers to accessing primary care. More tailored interventions are needed to meet the complex needs of adults with ≥18 visits per year.
TL;DR: In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool, however, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.
Abstract: Background The clinical severities of upper gastrointestinal bleeding (UGIB) are of a wide variety, ranging from insignificant bleeds to fatal outcomes. Several scoring systems have been designed to identify UGIB high- and low-risk patients. The aim of our study was to compare the Glasgow-Blatchford score (GBS) with the preendoscopic Rockall score (PRS) and the complete Rockall score (CRS) in their utilities in predicting clinical outcomes in patients with UGIB. Methods We designed a prospective study to compare the performance of the GBS, PRS, and CRS in predicting primary and secondary outcomes in UGIB patients. The primary outcome included the need for blood transfusion, endoscopic therapy, or surgical intervention and was labeled as high risk. The secondary outcomes included rebleeding and 30-day mortality. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values for each system were analyzed. A total of 303 consecutive patients admitted with UGIB during a 1-year period were enrolled. Results For prediction of high-risk group, AUC was obtained for GBS (0.808), PRS (0.604), and CRS (0.767). For prediction of rebleeding, AUC was obtained for GBS (0.674), PRS (0.602), and CRS (0.621). For prediction of mortality, AUC was obtained for GBS (0.513), PRS (0.703), and CRS (0.620). Conclusions In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool. However, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.
TL;DR: C-reactive protein is both a sensitive and specific marker for bacterial infection in patients presenting with ILI during the influenza season.
Abstract: Objective During the influenza season patients are labeled as having an influenza-like illness (ILI) which may be either a viral or bacterial infection. We hypothesize that C-reactive protein (CRP) levels among patients with ILI diagnosed with a bacterial infection will be higher than patients diagnosed with an influenza or another viral infection. Methods We enrolled a convenience sample of adults with ILI presenting to an urban academic emergency department from October to March during the 2008 to 2011 influenza seasons. Subjects had nasal aspirates for viral testing, and serum CRP. Bacterial infection was determined by positive blood cultures, radiographic evidence of pneumonia, or a discharge diagnosis of bacterial infection. Receiver operating characteristic curve, analysis of variance, and Student t test were used to analyze results. Results Over 3 influenza seasons there were 131 total patients analyzed (48 influenza infection, 42 other viral infection and 41 bacterial infection). CRP values were 25.65 mg/L (95% CI, 18.88-32.41) for influenza, 18.73 mg/L (95% CI, 12.97-24.49) for viral and 135.96 mg/L (95% CI, 99.38-172.54) for bacterial. There was a significant difference between the bacterial group, and both the influenza and other viral infection groups ( P 80 had a specificity of 100%. Conclusion C-reactive protein is both a sensitive and specific marker for bacterial infection in patients presenting with ILI during the influenza season.
TL;DR: Ultrasound imaging permits the evaluation of foot and ankle fractures and can be performed in the emergency department with confidence because it is a highly sensitive technique.
Abstract: Objectives Foot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas. Methods Ottawa Ankle Rules–positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US. Results One hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal. Conclusions Ultrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.
TL;DR: Patients are more likely to die when admitted through the ED on the weekend than those admitted on weekdays, and this study demonstrates a significant number of potentially preventable weekend deaths occurring annually in the United States.
Abstract: Primary objective The primary objective of the study is to determine if the mortality for adult patients visiting US emergency departments (EDs) is greater on weekends than weekdays. Secondary objectives The secondary objective of the study is to examine whether patient factors (diagnosis, income, insurance status) or hospital characteristics (ownership, ED volume, teaching status) are associated with increased weekend mortality. Methods We used a retrospective cohort analysis of the 2008 Nationwide Emergency Department Sample. Evaluating 4 225 973 adults admitted through the ED to the hospital, signifying a 20% representative sample of US ED admissions. Logistic regression was used to examine associations of weekend mortality with patient and hospital characteristics, accounting for clustering by hospital. Results Emergency department patients admitted to the hospital on the weekend are significantly more likely to die than those admitted on weekdays (odds ratio, 1.073; 95% confidence interval, 1.061-1.084). A significant weekend effect persisted after controlling for patient characteristics (odds ratio, 1.026; 95% confidence interval, 1.005-1.048). The top 10 primary diagnoses for patients dying did not identify any specific medical condition that explained the higher weekend admission mortality. The weekend effect was also relatively consistent across patient income, insurance status, hospital ownership, ED volume, and hospital teaching status. Conclusion Patients are more likely to die when admitted through the ED on the weekend. We were unable to identify specific circumstances or hospital attributes that help explain this phenomenon. Although the relative increased risk per case is small, our study demonstrates a significant number of potentially preventable weekend deaths occurring annually in the United States.
TL;DR: Current evidence does not support the routine use of serum PCT or CRP to rule in or rule out IE in patients suspected to have IE, and the global measures of accuracy, area under the receiver operating characteristic curve, and diagnostic odds ratio showed CRP may have higher accuracy than PCT.
Abstract: Background Infective endocarditis (IE) is a diagnostic challenge. We aimed to systemically summarize the current evidence on the diagnostic value of procalcitonin (PCT) in identifying IE. Methods We searched EMBASE, MEDLINE, Cochrane database, and reference lists of relevant articles with no language restrictions through September 2012 and selected studies that reported the diagnostic performance of PCT alone or compare with other biomarkers to diagnose IE. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models. Results We found 6 qualifying studies that included 1006 episodes of suspected infection with 216 (21.5%) confirmed IE episodes from 5 countries. Bivariate pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios were 64% (95% confidence interval [CI], 52%-74%), 73% (95% CI 58%-84%), 2.35 (95% CI 1.40-3.95), and 0.50 (95% CI 0.35-0.70), respectively. Of the 5 studies examining C-reactive protein (CRP), the pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios were 75% (95% CI 62%-85%), 73% (95% CI 61%-82%), 2.81 (95% CI 1.70-4.65), and 0.34 (95% CI 0.19-0.60), respectively. The global measures of accuracy, area under the receiver operating characteristic curve (AUC) and diagnostic odds ratio (dOR), showed CRP (AUC 0.80, dOR 8.55) may have higher accuracy than PCT (AUC 0.71, dOR 4.67) in diagnosing IE. Conclusions Current evidence does not support the routine use of serum PCT or CRP to rule in or rule out IE in patients suspected to have IE.
TL;DR: Low-dose ketamine combined with a reduced dose of hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.
Abstract: Objective We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain. Methods This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics. Results Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred. Conclusions Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.
TL;DR: SI, at a lowered threshold of ≥0.8, can be used to identify trauma patients that will require intervention for hemostasis, and is more specific in the older patients.
Abstract: Introduction The traditional method to identify hemorrhage after trauma has been vital signs–based. More recent attempts have used mathematical prediction models, but these are limited by the need for additional data including a Focused Assessment with Sonography for Trauma exam, or an arterial blood gas. Shock Index (SI) is the mathematical relationship of the heart rate divided by the systolic blood pressure; the cutoff of > 0.9 has been associated with bleeding. Methods A total of 4292 trauma patients were identified in database over an 11 year period. Inclusion criteria included age > 16 years and initial presentation to our trauma center. Patients were excluded for incomplete data, traumatic brain injury, or transfer leaving 4277 patients for analysis. Patients were further subdivided by age, and by mechanism of injury (blunt versus penetrating). Finally, patients were divided into bleeding versus nonbleeding, and the SI formula was applied to their initial hospital vital signs. Results Across our dataset, using the standard SI cutoff of > 0.9 as the threshold for bleeding, the sensitivity is 54.5%, with a specificity of 93.6%. In the geriatric subanalysis, there was no difference for sensitivity between the age groups, but SI is more specific in the older patients. There was no difference in sensitivity using SI in blunt versus penetrating. Lowering the SI to ≥ 0.8 increases the sensitivity to 76.1%, with a specificity of 87.4%. Conclusion SI, at a lowered threshold of ≥ 0.8, can be used to identify trauma patients that will require intervention for hemostasis.
TL;DR: Hypercalcemia is a rare but harmful electrolyte disorder in emergency department patients and unspecific symptoms such as a change in mental state, weakness, or gastrointestinal symptoms should prompt physicians to order serum calcium measurements, at least in patients with known malignancy or renal insufficiency.
Abstract: Purposes The aim of the study was to describe the prevalence, demographic, and clinical characteristics and etiologies of hypercalcemia in emergency department patients. Basic procedures In this retrospective cross-sectional descriptive study, all patients admitted between April 1, 2008, and March 31, 2011, to the emergency department of Inselspital, University Hospital Bern, were screened for the presence of hypercalcemia, defined as a serum calcium exceeding 2.55 mmol/L after correction for serum albumin. Demographic, laboratory, and outcome data were gathered. A detailed medical record review was performed to identify causes of hypercalcemia. Main findings During the study period, 14 984 patients (19% of all admitted patients) received a measurement of serum calcium. Of these, 116 patients (0.7%) presented with hypercalcemia. Median serum calcium was 2.72 mmol/L (first quartile, 2.64; third quartile, 2.88), with 4.3 mmol/L being the maximum serum calcium value observed. Underlying malignancy in 44% of patients and hyperparathyroidism in 20% (12% secondary and 8% primary) were the leading causes of hypercalcemia. Twenty-six percent of patients presented with symptomatic hypercalcemia. Weakness was the most common symptom of hypercalcemia, followed by nausea and disorientation. Principal conclusions Hypercalcemia is a rare but harmful electrolyte disorder in emergency department patients. Unspecific symptoms such as a change in mental state, weakness, or gastrointestinal symptoms should prompt physicians to order serum calcium measurements, at least in patients with known malignancy or renal insufficiency.
TL;DR: A 28-year-old-man admitted to emergency department with ventricular tachycardia was hospitalized and died on the third day after he had drunk 3 cans of 250-mL energy drink 5 hours before the basketball match.
Abstract: A 28-year-old-man admitted to emergency department with ventricular tachycardia. Patient had drunk 3 cans of 250-mL energy drink 5 hours before the basketball match; he had palpitation and nausea before the match. After 30 minutes of the match, during the break, patient lost his consciousness. On admission, normal cardiac rhythm was achieved by cardioversion, and the patient was hospitalized and died on the third day. Energy drinks generally contain caffeine, taurine, various vitamins, glucose, and herbal extracts such as guarana and ginseng. Especially in high doses, caffeine can cause palpitations and supraventricular and ventricular arrhythmia. Energy drink consumers should be informed about their severe adverse effects in case of overuse.