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Publisher: Elsevier   (Total: 3175 journals)

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Showing 1 - 200 of 3175 Journals sorted alphabetically
A Practical Logic of Cognitive Systems     Full-text available via subscription   (Followers: 8)
AASRI Procedia     Open Access   (Followers: 14)
Academic Pediatrics     Hybrid Journal   (Followers: 28, SJR: 1.402, h-index: 51)
Academic Radiology     Hybrid Journal   (Followers: 22, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 90, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 25, SJR: 0.612, h-index: 27)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 33, SJR: 2.515, h-index: 90)
Achievements in the Life Sciences     Open Access   (Followers: 5)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 6, SJR: 0.338, h-index: 19)
Acta Astronautica     Hybrid Journal   (Followers: 376, SJR: 0.726, h-index: 43)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 27, SJR: 2.02, h-index: 104)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 2)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 8, SJR: 0.172, h-index: 29)
Acta Haematologica Polonica     Free   (Followers: 1, SJR: 0.123, h-index: 8)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.604, h-index: 38)
Acta Materialia     Hybrid Journal   (Followers: 235, SJR: 3.683, h-index: 202)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.615, h-index: 21)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.442, h-index: 21)
Acta Oecologica     Hybrid Journal   (Followers: 10, SJR: 0.915, h-index: 53)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.311, h-index: 16)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 1)
Acta Poética     Open Access   (Followers: 4)
Acta Psychologica     Hybrid Journal   (Followers: 25, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.059, h-index: 77)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.383, h-index: 19)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 5, SJR: 0.141, h-index: 3)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3, SJR: 0.112, h-index: 2)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 6)
Acute Pain     Full-text available via subscription   (Followers: 14)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.967, h-index: 57)
Addictive Behaviors     Hybrid Journal   (Followers: 15, SJR: 1.514, h-index: 92)
Addictive Behaviors Reports     Open Access   (Followers: 7)
Additive Manufacturing     Hybrid Journal   (Followers: 9, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Cement Based Materials     Full-text available via subscription   (Followers: 3)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 128, SJR: 5.2, h-index: 222)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 11, SJR: 1.265, h-index: 53)
Advanced Powder Technology     Hybrid Journal   (Followers: 16, SJR: 0.739, h-index: 33)
Advances in Accounting     Hybrid Journal   (Followers: 8, SJR: 0.299, h-index: 15)
Advances in Agronomy     Full-text available via subscription   (Followers: 12, SJR: 2.071, h-index: 82)
Advances in Anesthesia     Full-text available via subscription   (Followers: 27, SJR: 0.169, h-index: 4)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 10, SJR: 1.054, h-index: 35)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 10, SJR: 0.801, h-index: 26)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 22, SJR: 1.286, h-index: 49)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 14, SJR: 3.31, h-index: 42)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.277, h-index: 43)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.619, h-index: 48)
Advances in Cancer Research     Full-text available via subscription   (Followers: 28, SJR: 2.215, h-index: 78)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 7, SJR: 0.9, h-index: 30)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 2.139, h-index: 42)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 3)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 12)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 27, SJR: 0.183, h-index: 23)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.665, h-index: 29)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.268, h-index: 45)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 28, SJR: 0.938, h-index: 33)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 19, SJR: 2.314, h-index: 130)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.223, h-index: 22)
Advances in Dermatology     Full-text available via subscription   (Followers: 14)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 10)
Advances in Digestive Medicine     Open Access   (Followers: 8)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 5)
Advances in Drug Research     Full-text available via subscription   (Followers: 21)
Advances in Ecological Research     Full-text available via subscription   (Followers: 42, SJR: 3.25, h-index: 43)
Advances in Engineering Software     Hybrid Journal   (Followers: 27, SJR: 0.486, h-index: 10)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 6)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 42, SJR: 5.465, h-index: 64)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 7)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 54, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 15)
Advances in Genetics     Full-text available via subscription   (Followers: 14, SJR: 2.558, h-index: 54)
Advances in Genome Biology     Full-text available via subscription   (Followers: 7)
Advances in Geophysics     Full-text available via subscription   (Followers: 6, SJR: 2.325, h-index: 20)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 21, SJR: 0.906, h-index: 24)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.497, h-index: 31)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 23)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 1, SJR: 0.396, h-index: 27)
Advances in Immunology     Full-text available via subscription   (Followers: 36, SJR: 4.152, h-index: 85)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 1.132, h-index: 42)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.274, h-index: 27)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 8, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 9)
Advances in Marine Biology     Full-text available via subscription   (Followers: 14, SJR: 1.645, h-index: 45)
Advances in Mathematics     Full-text available via subscription   (Followers: 10, SJR: 3.261, h-index: 65)
Advances in Medical Sciences     Hybrid Journal   (Followers: 6, SJR: 0.489, h-index: 25)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 5)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 4, SJR: 1.44, h-index: 51)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 21)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 3)
Advances in Oncobiology     Full-text available via subscription   (Followers: 1)
Advances in Organ Biology     Full-text available via subscription   (Followers: 1)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 15, SJR: 2.885, h-index: 45)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 6, SJR: 0.148, h-index: 11)
Advances in Parasitology     Full-text available via subscription   (Followers: 5, SJR: 2.37, h-index: 73)
Advances in Pediatrics     Full-text available via subscription   (Followers: 24, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 10)
Advances in Pharmacology     Full-text available via subscription   (Followers: 15, SJR: 1.718, h-index: 58)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 0.384, h-index: 26)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.248, h-index: 11)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 7)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 5)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 17)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 18, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 59)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.478, h-index: 32)
Advances in Radiation Oncology     Open Access  
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.1, h-index: 2)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 5)
Advances in Space Research     Full-text available via subscription   (Followers: 375, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
Advances in Surgery     Full-text available via subscription   (Followers: 9, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 29, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 17)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 13)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 46, SJR: 2.408, h-index: 94)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 0.973, h-index: 22)
Aerospace Science and Technology     Hybrid Journal   (Followers: 333, SJR: 0.816, h-index: 49)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.318, h-index: 36)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 9, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 429, SJR: 1.385, h-index: 72)
Agri Gene     Hybrid Journal  
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 15, SJR: 2.18, h-index: 116)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 43, SJR: 1.546, h-index: 79)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 1)
Agriculture and Natural Resources     Open Access   (Followers: 2)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 56, SJR: 1.879, h-index: 120)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.434, h-index: 14)
Air Medical J.     Hybrid Journal   (Followers: 5, SJR: 0.234, h-index: 18)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.285, h-index: 3)
Alcohol     Hybrid Journal   (Followers: 11, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 9)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 1, SJR: 0.436, h-index: 12)
Alexandria J. of Medicine     Open Access   (Followers: 1)
Algal Research     Partially Free   (Followers: 9, SJR: 2.05, h-index: 20)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.46, h-index: 29)
Allergology Intl.     Open Access   (Followers: 5, SJR: 0.776, h-index: 35)
Alpha Omegan     Full-text available via subscription   (SJR: 0.121, h-index: 9)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 9, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 48, SJR: 4.289, h-index: 64)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 4)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 6)
American Heart J.     Hybrid Journal   (Followers: 50, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 50, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 42, SJR: 0.574, h-index: 65)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 10, SJR: 1.091, h-index: 45)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 31, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 26, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 32, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 42, SJR: 2.023, h-index: 189)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 189, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 62, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 6)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.249, h-index: 88)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 27, SJR: 2.653, h-index: 228)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 27, SJR: 2.764, h-index: 154)
American J. of Surgery     Hybrid Journal   (Followers: 37, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.653, h-index: 70)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 6)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.066, h-index: 51)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 61, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 14)
Anales de Cirugia Vascular     Full-text available via subscription  
Anales de Pediatría     Full-text available via subscription   (Followers: 2, SJR: 0.209, h-index: 27)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription   (SJR: 0.104, h-index: 3)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 4, SJR: 2.577, h-index: 7)
Analytica Chimica Acta     Hybrid Journal   (Followers: 39, SJR: 1.548, h-index: 152)
Analytical Biochemistry     Hybrid Journal   (Followers: 165, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 10, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 11)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 1)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 22, SJR: 0.421, h-index: 40)
Angiología     Full-text available via subscription   (SJR: 0.124, h-index: 9)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1)

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Journal Cover American Journal of Emergency Medicine
  [SJR: 0.574]   [H-I: 65]   [42 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0735-6757
   Published by Elsevier Homepage  [3175 journals]
  • Comparison of bedside screening methods for frailty assessment in older
           adult trauma patients in the emergency department
    • Authors: Sachita P. Shah; Kevin Penn; Stephen J. Kaplan; Michael Vrablik; Karl Jablonowski; Tam N. Pham; May J. Reed
      Abstract: Publication date: Available online 14 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Sachita P. Shah, Kevin Penn, Stephen J. Kaplan, Michael Vrablik, Karl Jablonowski, Tam N. Pham, May J. Reed
      Background Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED). Methods We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC). Results Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84–0.98] or physician (AUROC 0.77 [95% CI 0.63–0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity and negative predictive value were 90.0% (54.1–99.5%) and 95.0% (73.1–99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard. Conclusion The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history.

      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.028
       
  • The gradient between arterial and end-tidal carbon dioxide predicts
           in-hospital mortality in post-cardiac arrest patient
    • Authors: Yong Won Kim; Sung Oh. Hwang; Hee Seung Kang; Kyoung-Chul Cha
      Abstract: Publication date: Available online 14 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Yong Won Kim, Sung Oh. Hwang, Hee Seung Kang, Kyoung-Chul Cha
      Purpose We investigated the predictive value of the gradient between arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (ETCO2) (Pa-ETCO2) in post-cardiac arrest patients for in-hospital mortality. Methods This retrospective observational study evaluated cardiac arrest patients admitted to the emergency department of a tertiary university hospital. The PaCO2 and ETCO2 values at 6, 12, and 24 h after return of spontaneous circulation (ROSC) were obtained from medical records and Pa-ETCO2 gap was calculated as the difference between PaCO2 and ETCO2 at each time point. Multivariate logistic regression analysis was performed to verify the relationship between Pa-ETCO2 gap and clinical variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of Pa-ETCO2 for predicting in-hospital mortality. Results The final analysis included 58 patients. In univariate analysis, Pa-ETCO2 gaps were significantly lower in survivors than in non-survivors at 12 h [12.2 (6.5–14.8) vs. 13.9 (12.1–19.6) mmHg, p = 0.040] and 24 h [9.1 (6.3–10.5) vs. 17.1 (13.1–23.2) mmHg, p < 0.001)] after ROSC. In multivariate analysis, Pa-ETCO2 gap at 24 h after ROSC was related to inhospital mortality [odds ratio (95% confidence interval): 1.30 (1.07–1.59), p = 0.0101]. In ROC curve analysis, the optimal cut-off value of Pa-ETCO2 gap at 24 h after ROSC was 10.6 mmHg (area under the curve, 0.843), with 77.8% sensitivity and 85.7% specificity. Conclusion The Pa-ETCO2 gap at 24 h after ROSC was associated with inhospital mortality in post-cardiac arrest patients.

      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.025
       
  • Incidental LAD stenosis identified on non–gated chest CTA
    • Authors: Nicholas Chan; Brian M. Yuen; Ji Yang; Stuart L. Cohen; Loukas Boutis; John N. Makaryus
      Abstract: Publication date: Available online 14 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Nicholas Chan, Brian M. Yuen, Ji Yang, Stuart L. Cohen, Loukas Boutis, John N. Makaryus
      A 57–year–old male former smoker presented to the Emergency Department (ED) with blurry vision, headache, and generalized weakness. He was hypoxic on room air and ECG showed sinus tachycardia. A CT pulmonary angiogram was ordered in the ED and revealed no pulmonary embolism but incidentally noted a likely significant stenosis in the proximal LAD. Subsequent cardiac catheterization revealed a 90% stenotic lesion with percutaneous coronary intervention leading to symptom resolution. Unlike coronary CTA, CTPA is performed with non–ECG gated helical scanning and generates motion artifacts associated with myocardial contraction. However, the timing of vascular contrast opacification during CTPA often allows for at least partial evaluation of the coronary arteries, especially ostial and proximal segments. Physicians ordering and evaluating noncardiac–focused CT chest studies, particularly in the ED, should remain cognizant of the radiographic appearance of underlying CAD, particularly life–threatening incidental coronary pathologies to allow for timely management and intervention.

      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.024
       
  • Fulminant type 1 diabetes mellitus with remarkable elevation of serum
           pancreatic enzymes
    • Authors: Mikio Nakajima; Masamitsu Shirokawa; Tomotsugu Nakano; Hideaki Goto
      Abstract: Publication date: Available online 14 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Mikio Nakajima, Masamitsu Shirokawa, Tomotsugu Nakano, Hideaki Goto
      Fulminant type 1 diabetes mellitus progresses extremely rapidly and is accompanied by ketoacidosis. Patients with the disease present at emergency departments with non-specific symptoms, including fever, nausea, vomiting, and abdominal pain. Here, we present a case of fulminant type 1 diabetes mellitus where the patient was initially misdiagnosed with gastroenteritis and acute pancreatitis. A 50-year-old Japanese woman was referred to our hospital with coma and shock. She had presented with nausea, vomiting, abdominal pain and thirst from 5 days before admission, and had been misdiagnosed with gastroenteritis by her primary care physician. Upon examination, metabolic acidosis and remarkable elevation of pancreatic exocrine enzymes were found (amylase 4322 IU/L, lipase 1046 IU/L). Acute pancreatitis was initially suspected because of the high pancreatic enzyme levels and abdominal pain. However, her plasma glucose level was markedly elevated at 1357 mg/dl. The patient was diagnosed with fulminant type 1 diabetes mellitus. Computed tomography showed no radiological evidence of acute pancreatitis. In conclusion, fulminant type 1 diabetes mellitus is often referred to hospital with flu-like or gastrointestinal symptoms and elevation of serum pancreatic enzymes. Physicians must be sure not to misdiagnose it as gastroenteritis or acute pancreatitis.

      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.026
       
  • Why might ALS have negative effects on patients with out-of-hospital
           cardiac arrest'
    • Authors: Jun-Zhao Liu; Sheng Ye; Yan-Wei Cheng; Peng Yao; Di Hao; Yu Cao
      Abstract: Publication date: Available online 13 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Jun-Zhao Liu, Sheng Ye, Yan-Wei Cheng, Peng Yao, Di Hao, Yu Cao


      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.023
       
  • The reduced use of intubations in elderly patients in the emergency
           department: Many insights behind a historical trend
    • Authors: Nicola Vargas; Antonio M. Esquinas
      Abstract: Publication date: Available online 12 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Nicola Vargas, Antonio M. Esquinas


      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.021
       
  • Impact of a CPRMeter feedback device on chest compression quality
           performer by nurses: A randomized crossover study
    • Authors: Roman Konski; Michal Cieciel; Marcin Madziala; Agnieszka Madziala
      Abstract: Publication date: Available online 12 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Roman Konski, Michal Cieciel, Marcin Madziala, Agnieszka Madziala


      PubDate: 2018-04-15T14:58:28Z
      DOI: 10.1016/j.ajem.2018.04.022
       
  • Chemotherapy patient with Stevens-Johnson Syndrome presents to the
           Emergency Department: A case report
    • Authors: Stephanie Widmer; Michele Grossman
      Abstract: Publication date: Available online 11 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Stephanie Widmer, Michele Grossman
      Background Stevens-Johnson syndrome (SJS) is part of a continuum of severe mucocutaneous reactions, commonly thought to be triggered by certain medications. The syndrome itself is characterized by diffuse necrosis and detachment of the epidermis. Case report This case report discusses a patient who presented to the Emergency Department with signs and symptoms of Stevens-Johnson syndrome four days after chemotherapy administration of ribociclib (Kisqali®). Ribociclib is a newly approved, cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor indicated for the treatment of hormone receptor positive, human epidermal growth factor receptor 2 negative (HR+/HER2−) metastatic breast cancer. Our case was a 70-year-old female patient with breast cancer who presented four days after her second administration of Ribociclib exhibiting skin findings consistent with SJS. Patient was transferred from the Emergency Department to a burn center for further management and diagnosis was confirmed by biopsy. Conclusions While Stevens-Johnson syndrome has been a rare toxicity, it is potentially fatal. The emergency physician should pay special attention cancer patients presenting with suspicious rashes and carefully review their medications.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.019
       
  • Effect of regional cerebral oximetry to estimate neurologic prognostic
           outcomes in patients administered targeted temperature management
    • Authors: Aykut Sarıtaş; Burcu Acar Çinleti; Çiler Zincircioğlu; Uğur Uzun; Işıl Köse; Nimet Şenoğlu
      Abstract: Publication date: Available online 9 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Aykut Sarıtaş, Burcu Acar Çinleti, Çiler Zincircioğlu, Uğur Uzun, Işıl Köse, Nimet Şenoğlu
      Purpose The aim of our study is to research the role and efficacy of cerebral oximetry in predicting neurologic prognosis when applied during TTM to patients experiencing coma after CA. Methods This study was performed on surviving adult comatose patients after CA treated with TTM. The average scores of rSO2 was measured at 6 h intervals for the first 2 days and once a day for the following 3 days with a NIRS device during TTM. The CPC scale was used to define the neurologic outcomes of patients. We compared the correlations of rSO2 values between good (CPC 1–2) and poor (CPC 3–5) neurologic outcomes in CA patients. Results There was no statistically significant difference identified between the prognosis groups in terms of rSO2, CPR durations, hemoglobin values and admission body temperature (p > 0.05). When the variation in rSO2 values over time is investigated, though there was no significant difference between the good and poor prognosis groups, it appeared to fall in the first 6 h in both prognosis groups. The median NT-proBNP and lactate values were observed to be higher in the poor prognosis group. Conclusion There is no significant correlation between rSO2 values and neurologic outcomes. Multimodal monitoring methods may be useful and further studies with a larger patient population are necessary in this area.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.016
       
  • Combining early post-resuscitation EEG and HRV features improves the
           prognostic performance in cardiac arrest model of rats
    • Authors: Chenxi Dai; Zhi Wang; Liang Wei; Gang Chen; Bihua Chen; Feng Zuo; Yongqin Li
      Abstract: Publication date: Available online 9 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Chenxi Dai, Zhi Wang, Liang Wei, Gang Chen, Bihua Chen, Feng Zuo, Yongqin Li
      Objective Early and reliable prediction of neurological outcome remains a challenge for comatose survivors of cardiac arrest (CA). The purpose of this study was to evaluate the predictive ability of EEG, heart rate variability (HRV) features and the combination of them for outcome prognostication in CA model of rats. Methods Forty-eight male Sprague-Dawley rats were randomized into 6 groups (n = 8 each) with different cause and duration of untreated arrest. Cardiopulmonary resuscitation was initiated after 5, 6 and 7 min of ventricular fibrillation or 4, 6 and 8 min of asphyxia. EEG and ECG were continuously recorded for 4 h under normothermia after resuscitation. The relationships between features of early post-resuscitation EEG, HRV and 96-hour outcome were investigated. Prognostic performances were evaluated using the area under receiver operating characteristic curve (AUC). Results All of the animals were successfully resuscitated and 27 of them survived to 96 h. Weighted-permutation entropy (WPE) and normalized high frequency (nHF) outperformed other EEG and HRV features for the prediction of survival. The AUC of WPE was markedly higher than that of nHF (0.892 vs. 0.759, p < 0.001). The AUC was 0.954 when WPE and nHF were combined using a logistic regression model, which was significantly higher than the individual EEG (p = 0.018) and HRV (p < 0.001) features. Conclusions Earlier post-resuscitation HRV provided prognostic information complementary to quantitative EEG in the CA model of rats. The combination of EEG and HRV features leads to improving performance of outcome prognostication compared to either EEG or HRV based features alone.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.017
       
  • Effectiveness of interventions to improve the efficiency of emergency
           department operations: An evidence map
    • Authors: Sean M. O'Neill; Isomi Miake-Lye; Christopher P. Childers; Selene Mak; Jessica M. Beroes; Melinda Maggard-Gibbons; Paul G. Shekelle
      Abstract: Publication date: Available online 9 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Sean M. O'Neill, Isomi Miake-Lye, Christopher P. Childers, Selene Mak, Jessica M. Beroes, Melinda Maggard-Gibbons, Paul G. Shekelle


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.012
       
  • A non-invasive method for removing a non-deflatable bladder catheter
    • Authors: Qing Cheng; Hiabo Zhang; Guoren Wang; Zhenxiang Liu; Qiong Sun; Zhiming Bai
      Abstract: Publication date: Available online 8 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Qing Cheng, Hiabo Zhang, Guoren Wang, Zhenxiang Liu, Qiong Sun, Zhiming Bai


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.015
       
  • Quantifying the operational impact of boarding inpatients on emergency
           department radiology services
    • Authors: Benjamin A. White; Stephen C. Dorner; Brian J. Yun; Michael H. Lev; Marjory A. Bravard; Anand M. Prabhakar; Ali S. Raja
      Abstract: Publication date: Available online 7 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Benjamin A. White, Stephen C. Dorner, Brian J. Yun, Michael H. Lev, Marjory A. Bravard, Anand M. Prabhakar, Ali S. Raja


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.013
       
  • Impact of rapid response car system on ECMO in out-of-hospital cardiac
           arrest
    • Authors: Junpei Komagamine
      Abstract: Publication date: Available online 7 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Junpei Komagamine


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.062
       
  • Time to successful completion of simulated pediatric lumbar puncture in
           lateral vs seated position: Comparison in novice providers
    • Authors: Bobbie Brotherson; John Flaherty; Elizabeth Gannon; Jestin Carlson; Melody Milliron
      Abstract: Publication date: Available online 7 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Bobbie Brotherson, John Flaherty, Elizabeth Gannon, Jestin Carlson, Melody Milliron


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.011
       
  • Pseudo-Wellens' syndrome and intermittent left bundle branch block in a
           case of acute cholecystitis
    • Authors: Steffen Grautoff; Martin Balog; Guenther Winde
      Abstract: Publication date: Available online 7 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Steffen Grautoff, Martin Balog, Guenther Winde
      We present a case of a 54-year-old male patient who was admitted to our Emergency Department (ED) with localized epigastric pain. Inflammation markers, ultrasound, and CT scan were inconsistent with an initial diagnosis of cholecystitis. However, there was additional evidence of cholecystolithiasis. The ECG showed new anterior biphasic T waves typical for a Wellens' type A ECG. Additionally, the patient had an intermittent left bundle branch block (LBBB). The diagnostic challenges in differentiating possible diagnoses will be described, to which in this case, were either acute cholecystitis or acute coronary syndrome (ACS). A laparoscopic study confirmed acute cholecystitis. Coronary angiography showed no pathological processes associated with ACS. ECG abnormalities were initially ongoing, but were no longer detectable during an 8 month follow up assessment.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.081
       
  • Association between body mass index and clinical outcomes of patients
           after cardiac arrest and resuscitation: A meta-analysis
    • Authors: Ye Ma; Lili Huang; Lu Zhang; Hai Yu; Bin Liu
      Abstract: Publication date: Available online 6 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Ye Ma, Lili Huang, Lu Zhang, Hai Yu, Bin Liu
      Background Obesity as one of the risk factors for cardiovascular diseases increases mortality in general population. Several clinical studies investigated clinical outcomes in patients with different body mass index (BMI) after cardiac arrest (CA). Controversial data regarding BMI on clinical outcomes in those patients exist in those studies. Therefore, we conducted a meta-analysis to evaluate the effect of BMI on survival condition and neurological prognosis in those patients. Methods We searched Pubmed, Embase, Ovid/Medline and EBM reviews databases for relational studies investigating the association between BMI and clinical outcomes of patients after CA. Seven studies involving 25,035 patients were included in this meta-analysis. Primary outcome was survival condition and secondary outcome was neurological prognosis. Three comparisons were conducted: underweight (BMI < 18.5) versus normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30) versus normal weight and obese (BMI ≥ 30) versus normal weight. Results Using normal weight patients as reference, underweight patients had a higher mortality (odds ratio [OR] 1.35; 95% confidence interval [CI] 1.10 to 1.66; P = 0.004; I2 = 17%). Overweight was associated with increased hospital survival (OR 0.80; 95% CI 0.65 to 0.98; P = 0.03; I2 = 62%) and better neurological recovery (OR 0.72; 95% CI 0.61 to 0.85; P < 0.001; I2 = 0%). No significant difference was found in clinical outcomes between obese and normal weight patients. Conclusions Low BMI was associated with lower survival rate in CA patients. Overweight was associated with a higher survival rate and better neurological recovery. Clinical outcomes did not differ between obese and normal weight patients. Further studies are needed to explore the underlying mechanisms.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.079
       
  • Is hallway care dangerous' An observational study
    • Authors: Jeffrey Rixe; James Liu; Hudson Breaud; Kerrie Nelson; Patricia Mitchell; James Feldman
      Abstract: Publication date: Available online 6 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Jeffrey Rixe, James Liu, Hudson Breaud, Kerrie Nelson, Patricia Mitchell, James Feldman
      Objectives In response to crowding the use of hallway beds has become an increasingly prevalent practice in Emergency Departments (EDs). There is limited research on whether caring for patients in hallways (HP) is associated with adverse outcomes. The goal of this study was to examine the effects of HP triage on 30 day outcomes for ED return, readmission, and mortality. Methods We performed a retrospective cohort study at an urban, academic ED comparing HPs (defined as HP for ≥30 min) to matched controls triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data from the hospital's clinical data warehouse. Matched controls were selected by gender, age, ethnicity, and language. We used McNemar's test to assess the association between triage location and 30 day study outcomes. We also examined adverse outcomes by triage severity using McNemar's test. Results A total of 10,608 HPs were matched to control patients. Compared to controls, HPs had 2.0 times the odds of returning to the ED in 30 days (95% CI: 1.8–2.1), 1.6 times the odds of inpatient readmission (95% CI: 1.4–1.9), and 1.7 times the odds of readmission to observation (95% CI: 1.4–2.0). The odds ratio for mortality in HPs versus controls was 0.80, (95% CI: 0.50–1.3). Conclusions Patients initially triaged to the hallway have an increased odds of 30 day return to the ED, observation and inpatient admission. After adjusting for ESI, the increased odds for return remained similar. The small sample size precluded testing effects of HP status on mortality.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.003
       
  • Ketamine versus ketamine pluses atropine for pediatric sedation: A
           meta-analysis
    • Authors: Jiaxiao Shi; Ang Li; Zhijian Wei; Yang Liu; Cong Xing; Hongyu Shi; Han Ding; Dayu Pan; Guangzhi Ning; Shiqing Feng
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Jiaxiao Shi, Ang Li, Zhijian Wei, Yang Liu, Cong Xing, Hongyu Shi, Han Ding, Dayu Pan, Guangzhi Ning, Shiqing Feng
      Objectives The application of atropine for pediatric sedation in the emergency department remains controversial. Our objective was to perform a comprehensive review of the literature and assess the clinical indexes in groups with and without atropine use. Methods PubMed, EMBASE, and the Cochrane Library were searched for randomized and non-randomized studies that compared ketamine and ketamine plus atropine for pediatric sedation. The risk ratio with 95% confidence interval was calculated using either a fixed- or random-effects model according to the value of I2. Results One retrospective study and four randomized controlled trials were identified to compare the clinical indexes. For the clinical indexes, the ketamine plus atropine group had better outcomes than the ketamine group in hypersalivation (P < 0.05), but indexes of rash and tachycardia were worse. The two methods of sedation were comparable for nausea, vomiting, desaturation, agitation and laryngospasm (P > 0.05). Conclusions Based on the current evidence, the group receiving atropine had reduced hypersalivation and increased rash and tachycardia; no differences were observed in nausea, vomiting, desaturation, agitation and laryngospasm between the two groups. Given that some of the studies were of low quality, additional high-quality randomized controlled trials should be conducted to further verify these findings.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.010
       
  • Impact of a low intensity and broadly inclusive ED care-coordination
           intervention on linkage to primary care and ED utilization
    • Authors: Sean D. Foster; Kim Hart; Christopher J. Lindsell; Christopher N. Miller; Michael S. Lyons
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Sean D. Foster, Kim Hart, Christopher J. Lindsell, Christopher N. Miller, Michael S. Lyons
      Objective We aim to evaluate the effectiveness of a broadly inclusive, comparatively low-intensity intervention linking ED patients to a primary care home. Methods This retrospective cohort study evaluated ED patients referred for primary care linkage in a large, urban, academic ED. A care coordination specialist performed a brief interview to gauge access barriers and provide a clinic referral with optional scheduling assistance. Data were abstracted from program records and the electronic medical record. The primary outcome was the proportion of referred individuals who attended at least one primary care appointment. Secondary outcomes included return ED encounters within one year, and. factors associated with linkage outcomes. Results There were 2142 referrals made for 2064 patients; 1688/2142 accepted assistance. Linkage was successful for 1059/1688 (63%, CI95 60% to 65%). Among patients accepting assistance, those without successful linkage were younger (41 vs 45 years, difference 3 years, CI95 2 to 3), more often male (62% vs 55%,difference 7%, CI95 2% to 12%), and less likely to have a chronic medical condition (37% vs 45%, difference 8%; CI95 3% to 12%) or to have had an appointment scheduled within two weeks (26% vs 33%, difference 7%, CI95 2% to 12%). Insurance status and self-reported barriers to care were not associated with linkage success. Patterns of subsequent ED use were similar, regardless of referral status or linkage outcome. Conclusion Low-intensity, broadly inclusive, ED care coordination linked nearly 50% of patients referred for intervention, and two-thirds of willing participants, with a primary care home.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.005
       
  • Refractory ventricular fibrillation in patient taking Lamictal
    • Authors: Andrew Dream; Helena Holmgren; Rebecca Merrill; Erin L. Simon
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Andrew Dream, Helena Holmgren, Rebecca Merrill, Erin L. Simon


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.008
       
  • Blood refill time: Clinical bedside monitoring of peripheral blood
           perfusion using pulse oximetry sensor and mechanical compression
    • Authors: Koichiro Shinozaki; Michael J. Capilupi; Kota Saeki; Hideaki Hirahara; Katsuyuki Horie; Naoki Kobayashi; Steve Weisner; Junhwan Kim; Joshua W. Lampe; Lance B. Becker
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Koichiro Shinozaki, Michael J. Capilupi, Kota Saeki, Hideaki Hirahara, Katsuyuki Horie, Naoki Kobayashi, Steve Weisner, Junhwan Kim, Joshua W. Lampe, Lance B. Becker


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.006
       
  • The early chain of care in bacteraemia patients: Early suspicion,
           treatment and survival in prehospital emergency care
    • Authors: Henrik Andersson; Christer Axelsson; Anna Larsson; Anders Bremer; Martin Gellerstedt; Angela Bång; Johan Herlitz; Lars Ljungström
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Henrik Andersson, Christer Axelsson, Anna Larsson, Anders Bremer, Martin Gellerstedt, Angela Bång, Johan Herlitz, Lars Ljungström
      Introduction Bacteraemia is a first stage for patients risking conditions such as septic shock. The primary aim of this study is to describe factors in the early chain of care in bacteraemia, factors associated with increased chance of survival during the subsequent 28days after admission to hospital. Furthermore, the long-term outcome was assessed. Methods This study has a quantitative design based on data from Emergency Medical Services (EMS) and hospital records. Results In all, 961 patients were included in the study. Of these patients, 13.5% died during the first 28days. The EMS was more frequently used by non-survivors. Among patients who used the EMS, the suspicion of sepsis already on scene was more frequent in survivors. Similarly, EMS personnel noted the ESS code “fever, infection” more frequently for survivors upon arriving on scene. The delay time from call to the EMS and admission to hospital until start of antibiotics was similar in survivors and non-survivors. The five-year mortality rate was 50.8%. Five-year mortality was 62.6% among those who used the EMS and 29.5% among those who did not (p<0.0001). Conclusion This study shows that among patients with bacteraemia who used the EMS, an early suspicion of sepsis or fever/infection was associated with improved early survival whereas the delay time from call to the EMS and admission to hospital until start of treatment with antibiotics was not. 50.8% of all patients were dead after five years.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.004
       
  • Acute streptococcal meningitis presenting as bilateral conductive hearing
           loss
    • Authors: Matthew J. Dougherty; Austin T. Smith
      Abstract: Publication date: Available online 5 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Matthew J. Dougherty, Austin T. Smith
      Bacterial meningitis is a relatively uncommon condition encountered in the emergency department and the constellation of symptoms varies. Hearing loss has been well documented in the literature as a complication of the disease process, but not as the presenting complaint. We describe a case of a 59-year-old female who presented to the emergency department with sudden onset bilateral hearing loss who was found to have S. pneumonia meningitis bacterial meningitis. Even with advances in therapy, bacterial meningitis still carries a significant mortality rate. Early diagnosis and treatment is critical to achieving good outcomes.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.009
       
  • A comparison of comfort assessment of NECKLITE vs. NeXsplint cervical
           collar. Pilot data
    • Authors: Michal Ladny; Lukasz Szarpak; Jacek Smereka; Jerzy R. Ladny
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Michal Ladny, Lukasz Szarpak, Jacek Smereka, Jerzy R. Ladny


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.078
       
  • Headache in a patient with influenza
    • Authors: Jill M. Fuller; Jestin Carlson; Jason Ball
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Jill M. Fuller, Jestin Carlson, Jason Ball
      Complications from influenza have been documented in the literature, but this patient case represents a rare and potentially deadly result in an otherwise healthy adult. Providers in the emergency department should be vigilant when assessing patients with influenza symptoms and monitoring those that don't always present with common symptoms and complaints. This patient's cerebral edema and tonsillar herniation was life-threatening and was caused from the influenza B virus.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.071
       
  • High sensitivity troponin: The Sisyphean pursuit of zero percent miss rate
           for acute coronary syndrome in the emergency department
    • Authors: Shane M. Summers; Brit Long; Michael D. April; Alex Koyfman; Curtis J. Hunter
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Shane M. Summers, Brit Long, Michael D. April, Alex Koyfman, Curtis J. Hunter
      Background The United States Food and Drug Administration recently approved a high sensitivity troponin (hsTn) assay for use. Recent literature has investigated the diagnostic accuracy of hsTn for acute coronary syndrome (ACS) in the emergency department (ED) and its use in accelerated diagnostic protocols. Objective This article evaluates the existing literature and discusses incorporation of hsTn testing into ED clinical practice based on best available evidence. Discussion Interpretation of this literature for clinical application is challenging due to heterogeneity across studies with regards to the hsTn assays examined, time intervals for delta troponin tests, and study populations. The high sensitivity of these assays is predicated upon the ability of the physician to clinically determine a patient to have a low pre-test probability of disease. Physicians may further ensure maximal sensitivity by defining the cut-off for a positive value as the limit of detection and utilizing delta troponin testing. These assays do not obviate the need to consider follow-up for risk stratification for discharged patients. Higher sensitivity compared to standard troponin tests comes at the expense of lower specificity. Indiscriminate testing may translate to greater numbers of abnormal troponin results in patients with non-ACS syndromes, potentially leading to increased healthcare costs, hospital admissions, increased ED lengths of stay, and unnecessary interventions. Conclusion As hsTn becomes more widespread, it is imperative emergency physicians understand its potential and limitations. Knowledge of test characteristics is vital to ensure appropriate use. Further study of hsTn is required to optimize use.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.075
       
  • Should paramedics use automated external defibrillators' Preliminary
           data
    • Authors: W. Gawel; W. Wieczorek; M. Dabrowski; H. Kaminska
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): W. Gawel, W. Wieczorek, M. Dabrowski, H. Kaminska
      Graphical abstract image

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.082
       
  • Aortic dissection presenting with acute pulmonary edema
    • Authors: Wan-Ching Lien; Chih-Hung Wang; Wei-Tien Chang; Ron-Bin Hsu; Wen-Jone Chen
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Wan-Ching Lien, Chih-Hung Wang, Wei-Tien Chang, Ron-Bin Hsu, Wen-Jone Chen


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.001
       
  • Association between acidosis and outcome in out-of-hospital cardiac arrest
           patients
    • Authors: Chi-Chun Lin; Cheng-Yu Lin; Chien-Hsiung Huang; Li-Heng Tsai; Chan-Wei Kuo; Cheng-Yu Chien
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Chi-Chun Lin, Cheng-Yu Lin, Chien-Hsiung Huang, Li-Heng Tsai, Chan-Wei Kuo, Cheng-Yu Chien


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.04.002
       
  • Assessment of five different probes for lung ultrasound in critically ill
           patients: A pilot study
    • Authors: Xavier Bobbia; Margaux Chabannon; Thierry Chevallier; Jean Emmanuel de La Coussaye; Jean Yves Lefrant; Sarah Pujol; Pierre-Géraud Claret; Laurent Zieleskiewicz; Claire Roger; Laurent Muller
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Xavier Bobbia, Margaux Chabannon, Thierry Chevallier, Jean Emmanuel de La Coussaye, Jean Yves Lefrant, Sarah Pujol, Pierre-Géraud Claret, Laurent Zieleskiewicz, Claire Roger, Laurent Muller
      Introduction The present study was aimed at comparing the diagnosis concordance of five echo probes of lung ultrasound (LUS) with CT scans in intensive care and emergency patients with acute respiratory failure. Materials This prospective, observational, pilot study involved 10 acute patients in whom a thoracic CT scan was performed. An expert performed an LUS reference exam using five different probes: three probes with a high-quality conventional echo machine (cardiac phased-array probe, abdominal convex probe, linear probe) and two probes (cardiac and linear) with a pocket ultrasound device (PUD). Then, a trained physician and a resident performed ‘blinded’ analyses by viewing the video results on a computer. The primary objective was to test concordance between the blinded echo diagnosis and the CT scan. Results In the 100 LUS performed, the phased-array probe of the conventional machine and linear array probe of the PUD have the best concordance with the CT scan (Kappa coefficient=0.75 [CI 95%=0.54–0.96] and 0.62 [CI 95%=0.37–0.86], respectively) only for experts and trained physicians. The agreement was always poor for residents. Convex (abdominal) and linear transducers of conventional machines and the phased-array transducers (cardiac) of PUD have poor or very poor agreement, regardless of the physician's experience. Conclusion Among the probes tested for LUS in acute patients, the cardiac probe of conventional machines and the linear probes of PUDs provide good diagnosis concordance with CT scans when performed by an expert and trained physician, but not by residents.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.077
       
  • Comparative analysis of incapacitated versus forcible sexual assault in a
           community-based population
    • Authors: Linda Rossman; Stephanie Solis; Lindsey Ouellette; Brook Woolley; Colleen Bush; J.S. Jones
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Linda Rossman, Stephanie Solis, Lindsey Ouellette, Brook Woolley, Colleen Bush, J.S. Jones


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.083
       
  • Compression with a pocket-sized ultrasound device to diagnose proximal
           deep vein thrombosis
    • Authors: Sarah Pujol; Jeremy Laurent; Thibaut Markarian; Pierre-Géraud Claret; Jean Yves Lefrant; Claire Roger; Laurent Muller; Jean Emmanuel de La Coussaye; Antonia Perez-Martin; Xavier Bobbia
      Abstract: Publication date: Available online 3 April 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Sarah Pujol, Jeremy Laurent, Thibaut Markarian, Pierre-Géraud Claret, Jean Yves Lefrant, Claire Roger, Laurent Muller, Jean Emmanuel de La Coussaye, Antonia Perez-Martin, Xavier Bobbia
      Introduction Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. Materials This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). Results The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. Conclusion CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.076
       
  • Diagnostic value of QRS and S wave variation in patients with suspicion of
           acute pulmonary embolism
    • Authors: Metin Çağdaş; Süleyman Karakoyun; İbrahim Rencüzoğulları; Yavuz Karabağ; İnanç Artaç; Doğan İliş; Şerif Hamideyin; Sibel Karayol; Handan Çiftçi; Tufan Çınar
      Abstract: Publication date: Available online 29 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Metin Çağdaş, Süleyman Karakoyun, İbrahim Rencüzoğulları, Yavuz Karabağ, İnanç Artaç, Doğan İliş, Şerif Hamideyin, Sibel Karayol, Handan Çiftçi, Tufan Çınar
      Background This study aimed to investigate the diagnostic value of QRS and S wave variation in patients admitted to the emergency department with suspicion of acute pulmonary embolism (APE). Method Computerized tomographic pulmonary angiography (CTPA) was performed in 118 consecutive patients to evaluate patients with suspected APE, and 106 subjects with appropriate electrocardiogram and CT images constituted the study population. Results Using CTPA, APE was diagnosed in 48.1% (n:51) of the study population. The comparison of patients with APE and those without APE revealed that increased heart rate, right axis deviation of QRS axis, complete or incomplete right bundle branch block, prominent S wave in lead D1, increased QRS duration, percentage of QRS (9,8[4,8–19,0] vs 3,8[2,7–71]; p <0,001), S wave variation (22,3[9,6–31,9] vs 4,8 [2-8]; p<0,001) and ΔS wave amplitude (1.1[0.5–1.5] vs 0.2[0.1–0.5]; p <0.001) were significantly associated with APE, but no relationship was detected with respect to the presence of atrial arrhythmias, clockwise rotation of the horizontal axis, fragmentation, ST segment deviation, T wave inversion, and S1Q3T3 and S1S2S3 patterns. The percentage of S wave variation (OR: 1072 per 1% increase, 95% CI:1011–1137) was found to be an independent predictor of APE. ΔS wave amplitude>0.5mm predicted APE with a sensitivity of 72.6% and a specificity of 74.6% (AUC:0.805, 95% CI: 0.717–0.876; p <0.001). Conclusion The present study demonstrated that QRS and S wave variation could be useful electrocardiographic signs for the diagnosis of APE.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.074
       
  • Factors associated with absent microhematuria in symptomatic urinary stone
           patients
    • Authors: Taek Hun Kim; Sang Hoon Oh; Kyu Nam Park; Han Joon Kim; Chun Song Youn; Soo Hyun Kim; Jeeyong Lim; Hyung Ki Moon; Hyo Joon Kim
      Abstract: Publication date: Available online 28 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Taek Hun Kim, Sang Hoon Oh, Kyu Nam Park, Han Joon Kim, Chun Song Youn, Soo Hyun Kim, Jeeyong Lim, Hyung Ki Moon, Hyo Joon Kim
      Introduction The aim of this study was to identify factors associated with absent hematuria in patients with symptomatic urinary stones. Methods This retrospective study analyzed the clinical and imaging findings of emergency department patients who underwent computed tomography (CT) for suspected ureteral colic over the past 2years. All patients also underwent a microscopic urinalysis, and the presence of 4 or more red blood cells/high-power field was defined as microhematuria. Results A total of 798 patients were included in this study. Of these patients, 750 (94.0%) presented with hematuria, while 48 (6.0%) urine samples did not have evidence of hematuria. The group with an absence of hematuria was more likely to have a lower stone location (located in an area from the distal ureter to the bladder) and perinephric stranding on CT than the hematuria group (75.0% vs. 54.3%, p=0.005; 47.9% vs. 30.5%, p=0.012, respectively). The degree of hematuria at each stone location was significantly different (p=0.001). In multivariate analysis, perinephric stranding (odds ratios (OR) 1.87 [95% confidence interval (CI) 1.01–3.46], p=0.047), a lower stone location (OR 2.72 [95% CI 1.37–5.36], p=0.004), and elevated serum blood urea nitrogen (BUN) levels (OR 1.06 [95% CI 1.01–1.12], p=0.026) were associated with absent hematuria. Conclusions In this large cohort of patients with renal colic, 6% had no microhematuria. Although some CT findings and elevated BUN were independently associated with hematuria absence, there was no difference in the demographics, time of presentation and degree and location of pain between the groups.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.069
       
  • Acute aortic occlusion in a patient without risk factors
    • Authors: Trina Stoneham; Erin L. Simon
      Abstract: Publication date: Available online 28 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Trina Stoneham, Erin L. Simon


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.073
       
  • A case of RapidRhino herniation causing airway obstruction
    • Authors: Bi Wen Lau; Alex Paspaliaris
      Abstract: Publication date: Available online 28 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Bi Wen Lau, Alex Paspaliaris
      Epistaxis is commonly managed with RapidRhino in emergency departments. We report a case of RapidRhino herniation during air inflation in a 99-year-old female, leading to significant airway obstruction. Upon re-inflation of the RapidRhino for persistent epistaxis, our patient suddenly developed acute respiratory distress. Throat examination revealed a large clot-like circular mass occluding the oropharynx. Initially mistaken as a massive blood clot, the mass was identified as the distal end of the RapidRhino. Immediate deflation of the RapidRhino results in spontaneous resolution of the respiratory distress. We hypothesise that the RapidRhino has herniated posteriorly into the oropharynx through excessive air inflation, potentially compounded by a product defect. Our case highlights a fatal consequence of RapidRhino application where emergency physicians should be cautious of, especially among inexperienced users.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.072
       
  • Vapocoolant spray versus placebo spray/no treatment for reducing pain from
           intravenous cannulation: A meta-analysis of randomized controlled trials
    • Authors: Yun Zhu; Xue Peng; Shuang Wang; Wenyu Chen; Yuanpeng Gao; Fenglan Lou
      Abstract: Publication date: Available online 27 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Yun Zhu, Xue Peng, Shuang Wang, Wenyu Chen, Yuanpeng Gao, Fenglan Lou
      Background Intravenous cannulation is a routine procedure in hospitalized patients, and pain can occur during the cannulation process. Vapocoolant spray is an advantageous analgesic alternative for intravenous cannula insertion. Objectives The objective of our meta-analysis is to compare the effectiveness of vapocoolant spray and placebo spray/no treatment for pain reduction during intravenous cannulation. Design A meta-analysis to identify evidence from randomized controlled trials. Methods We searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Data for publications before January 2018. The outcomes measured included pain during intravenous cannulation, patients' anxiety due to the spray, first attempt success rate, technical ease of the attempt, adverse events, and participant satisfaction. Results We included 11 studies with 1410 patients. The meta-analysis results showed that vapocoolant spray significantly decreased pain during intravenous cannulation compared with placebo spray or no treatment in both adults and children. In addition, vapocoolant spray significantly increased the technical ease of the attempt and participants' satisfaction. However, patients' anxiety due to spray, first attempt success rate, and adverse events were not associated with vapocoolant spray. Conclusions This meta-analysis suggests that vapocoolant spray significantly decreased pain during intravenous cannulation when compared with placebo spray or no treatment in both adults and children. We recommend the use of vapocoolant spray during intravenous cannulation to decrease pain. Future research may help to unify pain measurement standards. Patients' anxiety due to spray and technical ease of the attempt should be explored in future research.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.068
       
  • Characteristics and outcomes of reversed patients admitted to an emergency
           department for VKA-related intramuscular hematoma
    • Authors: F. Moustafa; L. Poujol; N. Vincent; J. Saint-Denis; N. Dublanchet; N. Breuil; S. Heuser; A. Lebreton; F. Dutheil; J. Schmidt
      Abstract: Publication date: Available online 27 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): F. Moustafa, L. Poujol, N. Vincent, J. Saint-Denis, N. Dublanchet, N. Breuil, S. Heuser, A. Lebreton, F. Dutheil, J. Schmidt
      Background According to the International Society on Thrombosis and Haemostasis (ISTH), intramuscular hematoma without other severity criteria is not considered a major bleeding. Objectives: In a large cohort of reversed vitamin K antagonist (VKA) patients admitted to the emergency unit for muscular hematoma, we assess frequency, severity, and anticoagulation management based on whether ISTH criteria were met or not. Materials and methods We performed a retrospective single-center study involving patients admitted to an emergency unit for VKA-induced intramuscular hematoma whose bleeding was reversed with prothrombin complex concentrates. Results During the study period, 631 VKA-induced bleeding events occurred in our emergency unit, of which 73 (11.6%) were intramuscular hematomas and half met ISTH criteria. The mean age was 75.5years (95% CI=72.6–78.3). Admission blood tests showed that patients with ISTH criteria had higher international normalized ratio (7.0±4.6 vs. 4.1±3.0, p=0.002) and lower hemoglobin (8.1±1.8 vs. 11.9±2.2, p<0.001) than those without. Patients with ISTH criteria were more likely to have intramuscular hematoma in the iliopsoas, gluteal, and pectoral muscles than those without. Interestingly, two-thirds of rectus sheath hematomas involved patients without ISTH criteria. However, patients with or without ISTH criteria exhibited a similar hospitalization duration and rate of re-bleeding. Conclusion We showed that half of the patients admitted with intramuscular hematoma could not be qualified as having ISTH-criteria major bleeding. Interestingly, these patients displayed a similar hospitalization duration and rate of re-bleeding to those with ISTH-criteria major bleeding.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.067
       
  • Comparison of drug administration logistics between prothrombin complex
           concentrates and plasma in the emergency department
    • Authors: Sumaiah J. Alarfaj; Daniel H. Jarrell; Asad E. Patanwala
      Abstract: Publication date: Available online 24 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Sumaiah J. Alarfaj, Daniel H. Jarrell, Asad E. Patanwala
      Background Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs. Methods This was a single center three-arm retrospective cohort study. Adult patients in the ED with bleeding were included. The primary outcome measure was the time from order to administration, which was compared between PCC3, PCC4, and FFP. The time from order to administration was also compared when the ED pharmacist was involved versus not involved in the care of patients receiving PCC. Results There were 90 patients included in the study cohort (30 in each group). The median age was 69years (IQR 57–82years), and 57% (n=52) were male. The median time from order to administration was 36min (IQR 20–58min) for PCC3, 34min (IQR 18–48min) for PCC4, and 92min (IQR 63–133) for FFP (PCC3 versus PCC4, p=0.429; PCC3 versus FFP, p<0.001; PCC4 versus FFP, p<0.001). The median time from order to administration was significantly decreased when the ED pharmacist was involved (24min [IQR 15–35min] versus 42min [IQR 32–59min], p<0.001). Conclusions Time from order to administration is faster with PCC than FFP. ED pharmacist involvement decreases the time from order to administration of PCC.

      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.064
       
  • Cardiopulmonary resuscitation on television: The TVMD study
    • Authors: R.A. Luz Ramirez; R.A. Alejandro Castañeda; Daryelle S. Varon; Sharon Einav; Salim R. Surani; Joseph Varon
      Abstract: Publication date: Available online 24 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): R.A. Luz Ramirez, R.A. Alejandro Castañeda, Daryelle S. Varon, Sharon Einav, Salim R. Surani, Joseph Varon


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.065
       
  • Cervical fasciitis and mediastinal abscess in a young healthy female
           patient undetected on X-ray or ultrasound
    • Authors: Meryl M. Abrams; Christopher B. Ponce; Xiao C. Zhang
      Abstract: Publication date: Available online 23 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Meryl M. Abrams, Christopher B. Ponce, Xiao C. Zhang


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.048
       
  • Naloxone access among an urban population of opioid users
    • Authors: Jenna K. Nikolaides; Lum Rizvanolli; Michael Rozum; Steven E. Aks
      Abstract: Publication date: Available online 23 March 2018
      Source:The American Journal of Emergency Medicine
      Author(s): Jenna K. Nikolaides, Lum Rizvanolli, Michael Rozum, Steven E. Aks


      PubDate: 2018-04-11T14:54:33Z
      DOI: 10.1016/j.ajem.2018.03.066
       
 
 
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