Showing papers in "Journal of Emergency Medicine in 2015"

Not Another Boring Lecture: Engaging Learners with Active Learning Techniques

Abstract: Background Core content in Emergency Medicine Residency Programs is traditionally covered in didactic sessions, despite evidence suggesting that learners do not retain a significant portion of what is taught during lectures. Discussion We describe techniques that medical educators can use when leading teaching sessions to foster engagement and encourage self-directed learning, based on current literature and evidence about learning. Conclusions When these techniques are incorporated, sessions can be effective in delivering core knowledge, contextualizing content, and explaining difficult concepts, leading to increased learning.

Nonobstructive Coronary Artery Disease and Risk of Myocardial Infarction

Abstract: RESULTS Among 37 674 patients, 8384 patients (22.3%) had nonobstructive CAD and 20 899 patients (55.4%) had obstructive CAD.Within 1 year, 845 patients died and 385 were rehospitalized for MI. Among patients with no apparent CAD, the 1-year MI rate was 0.11% (n = 8, 95% CI, 0.10%-0.20%) and increased progressively by 1-vessel nonobstructive CAD, 0.24% (n = 10, 95% CI, 0.10%-0.40%); 2-vessel nonobstructive CAD, 0.56% (n = 13, 95% CI, 0.30%-1.00%); 3-vessel nonobstructive CAD, 0.59% (n = 6, 95% CI, 0.30%-1.30%); 1-vessel obstructive CAD, 1.18% (n = 101, 95% CI, 1.00%-1.40%); 2-vessel obstructive CAD, 2.18% (n = 110, 95% CI, 1.80%-2.60%); and 3-vessel or LM obstructive CAD, 2.47% (n = 137, 95% CI, 2.10%-2.90%). After adjustment, 1-year MI rates increased with increasing CAD extent. Relative to patients with no apparent CAD, patients with 1-vessel nonobstructive CAD had a hazard ratio (HR) for 1-year MI of 2.0 (95% CI, 0.8-5.1); 2-vessel nonobstructive HR, 4.6 (95% CI, 2.0-10.5); 3-vessel nonobstructive HR, 4.5 (95% CI, 1.6-12.5); 1-vessel obstructive HR, 9.0 (95% CI, 4.2-19.0); 2-vessel obstructive HR, 16.5 (95% CI, 8.1-33.7); and 3-vessel or LM obstructive HR, 19.5 (95% CI, 9.9-38.2). One-year mortality rates were associated with increasing CAD extent, ranging from 1.38% among patients without apparent CAD to 4.30% with 3-vessel or LM obstructive CAD. After risk adjustment, there was no significant association between 1or 2-vessel nonobstructive CAD andmortality, but there were significant associations with mortality for 3-vessel nonobstructive CAD (HR, 1.6; 95% CI, 1.1-2.5), 1-vessel obstructive CAD (HR, 1.9; 95% CI, 1.4-2.6), 2-vessel obstructive CAD (HR, 2.8; 95% CI, 2.1-3.7), and 3-vessel or LM obstructive CAD (HR, 3.4; 95% CI, 2.6-4.4). Similar associations were noted with the combined outcome.

Intravenous lipid emulsion in the emergency department: a systematic review of recent literature.

Abstract: Background Intravenous lipid emulsion (ILE) has been broadly attempted in the resuscitation of neurologic and cardiac toxic drug overdoses, however, the role of ILE in the emergency department is poorly defined. Objective This review aims to identify recent literature on the use of ILE in humans as an antidote and to familiarize emergency providers with the indications, availability, dosing recommendations, and adverse reactions associated with ILE use. Methods A systemic literature search of MEDLINE, EMBASE, and major toxicology conference abstracts was performed for human cases using ILE as an antidote with documented clinical outcomes through January 2014. Results Ninety-four published articles and 40 conference abstracts were identified, 85% of which had positive outcomes. The most common indication for ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic xenobiotics were tricyclic-antidepressants and verapamil. Discussion No standard of care is defined for the use of ILE, although the American Heart Association recommends use in LAST, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability resultant from lipid-soluble xenobiotics. ILE should be administered per American Society of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory interference, pancreatitis, respiratory distress syndrome, and interference with vasopressors should be considered as risks but are uncommon. Conclusions In the setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may be considered for resuscitation by emergency physicians. As such, ILE may be stocked in emergency departments in close proximity to resuscitation rooms and areas where local nerve blocks are performed.

Acute bacterial skin and skin structure infections (ABSSSI): practice guidelines for management and care transitions in the emergency department and hospital.

Abstract: Background Acute bacterial skin and skin structure infections (ABSSSI), formally referred to as complicated skin and soft tissue infections, include infections with resistance to previously effective antimicrobials. Increasing dramatically in incidence, they have become a challenging medical problem associated with high direct and indirect costs to both the medical system and society. Objectives To describe the burden of ABSSSI and to explore multidisciplinary approaches to its management and new treatments that can be initiated in the emergency department. Discussion We offer a best practice model aimed at providing risk-stratified and convenient care for ABSSSI at the lowest possible cost, while minimizing complications, readmissions, and inappropriate antibiotic use. In doing so, we focus on the care provided by emergency physicians and hospitalists and the transition of management between them for inpatient care, as well as the facilitation of observation or direct-to-outpatient care for suitable patients. Conclusions A standard, consistent, and multidisciplinary approach to ABSSSI can streamline care, reduce admissions, support antimicrobial stewardship, and improve clinical and resource consumption outcomes.

A Common Source Outbreak of Severe Delirium Associated with Exposure to the Novel Synthetic Cannabinoid ADB-PINACA.

Abstract: Background Since 2009, synthetic cannabinoid (SC) use has emerged as a growing public health threat in the United States (US). Several outbreaks of unexpected, severe toxicity linked to SC use have been reported since 2012. Reports of varied and significant morbidity after SC use are expected to increase because newer compounds enter the marketplace more frequently as manufacturers attempt to circumvent regulatory efforts. Case Report We report a cluster of 7 patients who experienced a spectrum of anxiety, delirium, psychosis, and aggressive behaviors after smoking the same SC-containing product at a party. An 8th patient with the same exposure source presented with delayed onset seizures. Biologic samples were analyzed for novel, newly identified SCs belonging to the FUBINACA family of compounds. A previously unknown SC, N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide (ADB-PINACA) was identified in biologic samples from 7 of the individuals. ADB-PINACA was identified in the SC-containing product (“Crazy Clown”) seized by law enforcement and identified as the product smoked by the 8 patients in the reported cluster. Why Should an Emergency Physician Be Aware of This? The information compiled using this cluster of cases, and a similar reported outbreak of altered mental status in Colorado, implicating the same SC (ADB-PINACA) and brands of SC-containing products, aided the US Drug Enforcement Administration in its temporary scheduling of ADB-PINACA and three other SCs. In this outbreak, close cooperation between public health and law enforcement allowed for a rapid intervention, which halted the outbreak by interrupting the common source and accelerated regulatory efforts to prevent further morbidity and mortality.

A comparison of three self-report pain scales in adults with acute pain.

Abstract: Background Several pain rating methods are used to quantify pain. Although these instruments have been extensively studied, their inter-agreement, especially in emergency department (ED) settings, has yet to be determined. Objective This study was designed to assess the agreement between Visual Analog Scale (VAS), Color Analog Scale (CAS), and verbally administered Numeric Rating Scale (NRS) in the emergency setting. Methods A sample of 150 adult patients presenting with acute pain to two EDs was recruited. Patients' pain severity at presentation, 30 and 60 min later was assessed using the three pain scales. The agreement between pain scales was assessed using Bland-Altman method and Spearman correlation. We described a composite measure to serve as the gold standard and to be compared with each score. Factor analysis was also performed to assess the underlying construct. Results Spearman correlation coefficients between NRS and CAS, NRS and VAS, and CAS and VAS were 0.95, 0.94, and 0.94, respectively ( p p Conclusions The three pain scales were strongly correlated at all time periods. The findings suggest that NRS, CAS, and VAS can be interchangeably applied for acute pain measurement in adult patients.

Acute Pancreatitis: What's the Score?

Abstract: Background Acute pancreatitis (AP) is a common presentation in the emergency department (ED). Severity of pancreatitis is an important consideration for ED clinicians making admission judgments. Validated scoring systems can be a helpful tool in this process. Objective The aim of this review is to give a general outline on the subject of AP and compare different criteria used to predict severity of disease for use in the ED. Discussion This review updates the classifications and scoring systems for AP and the relevant parameters of each. This article assesses past and current scoring systems for AP, including Ranson criteria, Glasgow criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography imaging scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Harmless Acute Pancreatitis Score (HAPS), and the Japanese Severity Score. This article also describes the potential use of single variable predictors. Finally, this article discusses risk factors for early readmission, an outcome pertinent to emergency physicians. These parameters may be used to risk-stratify patients presenting to the ED into mild, moderate, and severe pancreatitis for determination of appropriate disposition. Conclusion Rapid, reliable, and validated means of predicting patient outcome from rapid clinical assessment are of value to the emergency physician. Scoring systems such as BISAP, HAPS, and single-variable predictors may assist in decision-making due to their simplicity of use and applicability within the first 24 h.

Paramedic-performed Fascia Iliaca Compartment Block for Femoral Fractures: A Controlled Trial.

Abstract: Background Femoral (thigh) fractures are an important clinical problem commonly encountered by paramedics. These injuries are painful, and the need for extrication and transport adds complexity to the management of this condition. Whereas traditional analgesia involves parenteral opioids, regional nerve blockade for femoral fractures have been demonstrated to be effective when performed by physicians. Regional peripheral nerve blockade performed by paramedics may be suitable in the prehospital setting. Study Objectives To examine the efficacy and feasibility of paramedic-performed fascia iliaca compartment block (FICB) for patients with suspected hip or femur fractures in the prehospital setting compared to intravenous morphine alone. Methods Prior to treatment allocation, all patients received a loading dose of morphine intravenously, then received either 1) FICB using lidocaine with epinephrine; or 2) standard care (further intravenous morphine only) in this nonblinded, randomized control trial. Participants rated their pain using a standard 11-point verbal numerical rating scale prior to and 15 min after receiving the allocated treatment. Secondary outcomes included effectiveness at other time points and incidence of adverse effects. Results We analyzed 11 and 13 patients in the FICB and standard care groups, respectively. Patients treated with FICB had a greater reduction in their median pain score than patients in the standard care group (50% vs. 22%, p = 0.025) after 15 min. In the FICB group, median pain scores decreased by 5 (interquartile range 4–6), compared to 2 (interquartile range 0–4) in the standard care group. The FICB procedure did not significantly impact on scene times. No immediately obvious adverse events were noted in the 11 participants who received FICB from paramedics. Conclusion The study suggests that FICB can be performed by trained paramedics for patients with suspected femoral fractures.

Ketamine use for acute agitation in the emergency department

Abstract: Background Emergency physicians regularly encounter agitated patients. In extremely agitated and violent patients, the onset of many traditional medications is relatively slow and often requires additional medication. Ketamine is frequently used in emergency departments (EDs) for procedural sedation and intubation, but has recently been suggested as a treatment for acute agitation. Objectives We sought to examine the use of ketamine in the treatment of acute agitation in an ED setting, including vital sign changes as a result of this medication. Methods This is a structured review of an historical cohort of patients over 7 years at two university EDs. Patients were included if they received ketamine as treatment for acute agitation. Abstracted data included age, vital signs including hypoxia, any additional medications for agitation, and alcohol/drug intoxication. Results Ketamine was administered for agitation on 32 visits involving 27 patients. Preadministration systolic blood pressure was 131 ± 20 mm Hg, with an average postadministration increase of 17 ± 25 mm Hg. The average baseline heart rate was 98 ± 23 beats/min, with an average increase of 8 ± 17 beats/min. No patients became hypoxic; 62.5% of patients required additional calming medication. Alcohol or drug intoxication was present in 40.6% of patients. Conclusions We found ketamine was used rarely, but had few major adverse effects on vital signs even in a population with 21.9% alcohol intoxication. However, a high proportion (62.5%) of patients required additional pharmacologic treatment for agitation, implying that administering ketamine is useful only for initial control of severe agitation.

Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department.

Abstract: Background Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter (AFF) in the emergency department (ED). However, there is considerable regional variability in emergency physician practice patterns and debate among physicians as to which agent is more effective. To date, only one small prospective, randomized trial has compared the effectiveness of diltiazem and metoprolol for rate control of AFF in the ED and concluded no difference in effectiveness between the two agents. Objective Our aim was to compare the effectiveness of diltiazem with metoprolol for rate control of AFF in the ED. Methods A convenience sample of adult patients presenting with rapid atrial fibrillation or flutter was randomly assigned to receive either diltiazem or metoprolol. The study team monitored each subject's systolic and diastolic blood pressures and heart rates for 30 min. Results In the first 5 min, 50.0% of the diltiazem group and 10.7% of the metoprolol group reached the target heart rate (HR) of p p Conclusions Diltiazem was more effective in achieving rate control in ED patients with AFF and did so with no increased incidence of adverse effects.

Accuracy of optic nerve sheath diameter measurement by emergency physicians using bedside ultrasound.

Abstract: Background Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) has been utilized as an indirect assessment of intracranial pressure. It is usually performed by trained ultrasonographers. Objectives To evaluate whether or not emergency physicians (EP) are capable of measuring the ONSD accurately by US. Materials and Methods A retrospective measurement of ONSD was conducted on computed tomography (CT) scans of the head or facial bones. These patients had undergone ocular US performed by EPs prior to CT scanning. The CT scan measurements of ONSD read by a board-certified radiologist were compared with that of the US read by a registered diagnostic medical sonographer. A difference in measurements of the ONSD ≥ 0.5 mm between the two modalities was considered as significant for this study. Results The ONSD measurements were performed with CT scan and compared to that of the US. Of the 61 patients studied, 36 (59%) were male and 25 (41%) were female. The average age was 56 ± 17 years. All but 3 patients had ONSD measurements that were between 5 and 6 mm. Discrepancy in measurements of the ONSD between US and CT for both groups fell within our predetermined value (0.5 mm) for the majority of cases. None of the measurements were above 6 mm. The intraclass correlation coefficient was 0.9 (95% confidence interval 0.8846–0.9303). Conclusion Emergency physicians were capable of accurately measuring the ONSD using bedside US. Prospective studies with a larger sample size are recommended to validate these findings.

Predictors of a Top Performer During Emergency Medicine Residency.

Abstract: Background Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. Objective To evaluate which pre-residency variables best correlated with an applicant's performance during residency. Methods This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. Results A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, “global rating” and “competitiveness” on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. Conclusion We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.

Synthetic cannabinoid abuse in adolescents: a case series

Abstract: BACKGROUND: Synthetic cannabinoids, referred to as "Bonzai" in Turkey, are relatively new recreational drugs of abuse. Although the use of synthetic cannabinoids has been dramatically increasing in young populations in many countries, their adverse effects are not well known. OBJECTIVES: To report on the clinical features and social history of pediatric patients with a diagnosis of synthetic cannabinoid intoxication and to highlight the dangers of these drugs to public health. METHODS: We retrospectively reviewed 16 cases presenting to our Emergency Department (ED) with synthetic cannabinoid intoxication in the last 10 months. Usage characteristics and the psychoactive, physical, and metabolic effects of synthetic cannabinoids were analyzed. RESULTS: The mean age of the 16 patients with a diagnosis of synthetic cannabinoid intoxication was 15.4 ± 1.7 years (15 males, 1 female). The most common physical symptoms were eye redness, nausea/vomiting, sweating, and altered mental status; the main psychoactive findings were agitation, anxiety, hallucinations, and perceptual changes. We observed hypotension and bradycardia in 8 (50%) and 5 (31.3%) of the patients, respectively. Although most patients were discharged from the ED, 25% were transferred to an intensive care unit. They all had reduced school attendance and performance. The rates of cigarette smoking and alcohol drinking were also significantly higher. CONCLUSION: Synthetic cannabinoids are unsafe and potentially harmful drugs of abuse; they may even cause life-threatening effects. It is important for pediatricians to be familiar with the signs and symptoms of consumption of synthetic cannabinoid products. Education of parents, teachers, and adolescents about the potential health risks of using these products is essential. Language: en

Impact of In-Hospital Timing to Appendectomy on Perforation Rates in Children with Appendicitis.

Abstract: Background There is controversy regarding whether in-hospital time delay to appendectomy in children with appendicitis affects risk for perforation. Objective Our aim was to evaluate the impact of time delay from emergency department (ED) presentation to operating room (OR) appendectomy on rates of developing appendiceal perforation in children who present with computed tomography (CT)–confirmed, uncomplicated (no radiographic evidence of perforation) appendicitis. Methods We conducted a retrospective case review of 248 consecutive children aged ≤18 years with CT-confirmed uncomplicated appendicitis during a 4-year period. Results There were 149 males and 99 females, all received subsequent appendectomy. Despite all receiving ED parenteral antibiotic therapy, 54 (22%) developed in-hospital appendiceal perforation (surgeon operative observation or pathologist histologic analysis). No patient developed perforation when appendectomy was performed within 9 h after ED presentation; the rate of perforation was approximately sixfold greater in those with in-hospital delay >9 h (25%) vs. ≤9 h (4.6%). The rate of developing perforation increased to 21% during hours 9–24, and 41% after 24 h. Regression analysis showed three factors were significantly associated with developing perforation: longer mean time delay from ED presentation to OR appendectomy, presence of fever, and presence of an appendicolith. The risk for developing perforation increased by 1.10 for each hour of time delay from ED presentation to OR appendectomy; the estimated odds ratios for developing perforation per interval of in-hospital delay were 2.05 at 8 h, 4.22 at 16 h, and 8.67 at 24 h. Conclusions Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendiceal perforation in children who present with CT-documented uncomplicated appendicitis. Risk is approximately sixfold greater in those who experience delay >9 h vs. those whose delay is ≤9 h. Antibiotic therapy does not reliably prevent progression of the disease. Appendectomy should be considered an urgent procedure to maximize outcomes and prevent complications associated with appendix perforation.

Age-Related Emergency Department Reliance in Patients with Sickle Cell Disease

Abstract: Background Emergency Department Reliance (EDR: total emergency department [ED] visits/total ambulatory [outpatient + ED] visits) differentiates acute episodic ED users from those who may not have adequate access to outpatient care. Objective This study's aim was to investigate age-related patterns of EDR and associated health-care costs in pediatric patients with sickle cell disease (SCD) and those transitioning from pediatric to adult care. Methods State Medicaid data were used for this study. Patients with two or more SCD diagnoses and one or more blood transfusion were included. Quarterly rates of ED visits, EDR, SCD complications associated with ED visits, and ED visits resulting in hospitalization were evaluated. Risk factors associated with high EDR and the association between high EDR and health-care costs were explored through regression analyses. Results A total of 3208 patients were included. The most common SCD complications associated with ED visits were pain, infection, and pneumonia. Beginning at the age of 15 years, EDR rose from 0.17 to 0.29 visits per quarter at age 22 years, and remained high throughout adulthood. Regression analyses indicated that patients were most likely to have high EDR during the post-transition period and when experiencing an SCD complication. Patients with high EDR incurred statistically significantly higher inpatient and ED costs, resulting in significantly higher total health-care costs. Conclusions Compared to children, patients transitioning to adulthood relied more on the ED for their care. In addition, patients with high EDR incurred more days in the hospital and significantly higher health-care costs, highlighting the need to improve transition-related support, including better access to primary care and increased engagement with patients with SCD.

United states emergency department visits coded for intimate partner violence

Abstract: Background Limited information exists about medical treatment for victims of intimate partner violence (IPV). Objective Our aim was to estimate the number of emergency department (ED) visits and subsequent hospitalizations that were assigned a code specific to IPV and to describe the clinical and sociodemographic features of this population. Methods Data from the Nationwide Emergency Department Sample from 2006−2009 were analyzed. Cases with an external cause of injury code of E967.3 (battering by spouse or partner) were abstracted. Results From 2006−2009, there were 112,664 visits made to United States EDs with an e-code for battering by a partner or spouse. Most patients were female (93%) with a mean age of 35 years. Patients were significantly more likely to reside in communities with the lowest median income quartile and in the Southern United States. Approximately 5% of visits resulted in hospital admission. The mean charge for treat-and-release visits was $1904.69 and $27,068.00 for hospitalizations. Common diagnoses included superficial injuries and contusions, skull/face fractures, and complications of pregnancy. Females were more likely to experience superficial injuries and contusions, and males were more likely to have open wounds of the head, neck, trunk, and extremities. Conclusions From 2006 to 2009, there were approximately 28,000 ED visits per year with an e-code specific to IPV. Although a minority, 7% of these visits were made by males, which has not been reported previously. Future prospective research should confirm the unique demographic and geographic features of these visits to guide development of targeted screening and intervention strategies to mitigate IPV and further characterize male IPV visits.

Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator.

Abstract: Background Intravenous tissue-plasminogen activator remains the only U.S. Food and Drug Administration-approved treatment for acute ischemic stroke. Timely administration of fibrinolysis is balanced with the need for accurate diagnosis. Stroke mimics represent a heterogeneous group of patients presenting with acute-onset focal neurological deficits. If these patients arrive within the extended time window for acute stroke treatment, these stroke mimics may erroneously receive fibrinolytics. Objective This review explores the literature and presents strategies for differentiating stroke mimics. Discussion Clinical outcome in stroke mimics receiving fibrinolytics is overwhelmingly better than their stroke counterparts. However, the risk of symptomatic intracranial hemorrhage remains a real but rare possibility. Certain presenting complaints and epidemiological risk factors may help differentiate strokes from stroke mimics; however, detection of stroke often depends on presence of posterior vs. anterior circulation strokes. Availability of imaging modalities also assists in diagnosing stroke mimics, with magnetic resonance imaging offering the most sensitivity and specificity. Conclusion Stroke mimics remain a heterogeneous entity that is difficult to identify. All studies in the literature report that stroke mimics treated with intravenous fibrinolysis have better clinical outcome than their stroke counterparts. Although symptomatic intracranial hemorrhage remains a real threat, literature searches have identified only two cases of symptomatic intracranial hemorrhage in stroke mimics treated with fibrinolytics.

A comparison of accidental and nonaccidental trauma: it is worse than you think

Abstract: BACKGROUND: Child abuse, or nonaccidental trauma (NAT), is a major cause of pediatric morbidity and mortality, and is often unrecognized. Our hypothesis was that injuries due to accidental trauma (AT) and NAT are significantly different in incidence, injury, severity, and outcome, and are often unrecognized. OBJECTIVE: Our aim was to carry out an examination of the differences between pediatric injuries due to AT and NAT regarding incidence, demographics, injury severity, and outcomes. METHODS: A 4-year retrospective review of the Trauma Registry at Children's Medical Center Dallas, a large Level I pediatric trauma center, comparing incidence, age, race, trauma activation, intensive care unit (ICU) need, Injury Severity Score (ISS), and mortality between AT and NAT patients was carried out. RESULTS: There were 5948 admissions, 92.5% were AT and 7.5% were NAT victims. The NAT patients were younger (1.8 ± 3.3 years vs. 6.8 ± 4.2 years for AT patients; p CONCLUSIONS: NAT victims differ significantly from the AT patients, with a greater severity of injury and a 6-fold higher mortality rate. Delayed recognition of NAT occurred in almost 20% of the cases. It is generally accepted that NAT is underestimated. Its increased mortality rate and severity of injury are also not well recognized compared to the typical pediatric trauma child. Language: en

The Hartford Consensus on Active Shooters: Implementing the Continuum of Prehospital Trauma Response

Abstract: Background Active shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders. Objective To develop and implement tiered educational programs designed to teach police officers and lay bystanders the principles of initial trauma care and bleeding control using as a foundation the U.S. military's Tactical Combat Casualty Care course and the guidelines of the Committee on Tactical Emergency Casualty Care. Discussion The Tactical Casualty Care for Law Enforcement and First Responders course is a 1-day program combining didactic lecture, hands-on skills stations, and clinical scenarios designed primarily for police officers. The Bleeding Control for the Injured is a 2- to 3-h program for the potential citizen responder in the skills of hemorrhage control. In addition, we document the application of these skills by law enforcement officers and first responders in several real-life incidents involving major hemorrhage. Conclusions Developing and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival.

Emergency Visits for Prescription Opioid Poisonings.

Abstract: Background Prescription opioid abuse and overdose has steadily increased in the United States (US) over the past two decades, and current research has shown a dramatic increase in hospitalizations resulting from opioid poisonings. Still, much is unknown about the clinical and demographic features of patients presenting to emergency departments (EDs) for poisoning from prescription drugs. Objective We sought to evaluate ED visits by adults for prescription opioids. Methods This was a retrospective cohort study utilizing 2006–2011 data from the Nationwide Emergency Department Sample. Total number of admissions (weighted), disposition, gender, age, expected payer, income, geographic region, charges, and procedures performed were examined. Results From 2006 through 2010, there were 259,093 ED visits by adults for poisoning by opioids, and 53.50% of these were unintentional. The overall mean age of patients was 45.5 years, with more visits made by females (52.37%). Patients who unintentionally overdosed were more likely to have Medicare (36.54%), whereas those who intentionally overdosed had private insurance (29.41%). The majority of patients resided in the South (40.93%) and came from lower-income neighborhoods. Approximately 108,504 patients were discharged, and 140,395 were admitted. Conclusions There were over 250,000 visits to US EDs from 2006 through 2011 with a primary diagnosis of poisoning by a prescription opioid. Females made the majority of visits, and over half were admitted to the hospital, resulting in over $4 billion in charges. Future studies should examine preventative measures, optimal screening, and intervention programs for these patients.