Publisher: Elsevier   (Total: 3161 journals)

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Showing 1 - 200 of 3161 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 39, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 106, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 44, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 7)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 6)
Acta Astronautica     Hybrid Journal   (Followers: 447, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 30, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 12, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 5, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 325, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 2, SJR: 1.793, CiteScore: 6)
Acta Psychologica     Hybrid Journal   (Followers: 26, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access   (Followers: 1)
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 13, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 190, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 13, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 17, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 30, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 12, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 12, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 1, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 35, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 5)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 11, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 11, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 26, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 21, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 16)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 14)
Advances in Digestive Medicine     Open Access   (Followers: 13)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 45, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 30, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 9)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 51, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 2)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 68, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 12, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 8, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 26)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 3, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 37, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 9, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 17, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 9, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 26)
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: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 6, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 19)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 11)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 69)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 7, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 3, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 7)
Advances in Space Research     Full-text available via subscription   (Followers: 430, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 6)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 57, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 396, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 491, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 32, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 47, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 8, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 12)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 11, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 55, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 6, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 6, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 58, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 67, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 48, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 13)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 15, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 40, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 29, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 37, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 50)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 266, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 67, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 32, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 30, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 67, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 25, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 6, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 214, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 239, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 8, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)
Annales d'Endocrinologie     Full-text available via subscription   (Followers: 3, SJR: 0.451, CiteScore: 1)

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Similar Journals
Journal Cover
American Journal of Emergency Medicine
Journal Prestige (SJR): 0.604
Citation Impact (citeScore): 1
Number of Followers: 48  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0735-6757 - ISSN (Online) 1532-8171
Published by Elsevier Homepage  [3161 journals]
  • A potential association between myocardial ischemia and epinephrine for
           anaphylaxis: A case report and literature review
    • Abstract: Publication date: Available online 18 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Seigo Urushidani, Akira KuriyamaAbstractA previously healthy 60-year-old man presented to our emergency department with anaphylactic shock. We initiated fluid resuscitation with Ringer's lactate solution; injected 0.3 mg epinephrine intramuscularly; and administered d-chlorpheniramine maleate 5 mg, famotidine 20 mg, and methylprednisolone 80 mg intravenously. His symptoms resolved within 10 min. Thirty minutes after the epinephrine injection, he complained of sudden chest discomfort. Physical examination provided no evidence of anaphylaxis. The 12-lead electrocardiogram (ECG) showed ST-segment depression on leads II, III, aVF, and V3-6. Transthoracic echocardiography revealed normal ventricular contraction. After administration of 0.3 mg of sublingual nitroglycerin, his chest pain resolved immediately and his ECG normalized. A coronary angiogram showed normal coronary artery perfusion. The next day, his high-sensitivity troponin I was slightly elevated. We suspected that he had myocardial ischemia caused by coronary artery spasm. The symptoms of biphasic reaction of anaphylaxis are inconsistent, and using epinephrine for myocardial ischemia following anaphylaxis may aggravate the condition. Nonetheless, epinephrine is the drug of choice for treating anaphylaxis with critical airway, respiratory, and circulatory compromise. Thus, physicians should not hesitate to use epinephrine for patients who present with life-threatening conditions due to suspected anaphylaxis. Physicians should observe patients closely following epinephrine administration, and if they develop some symptoms, should carefully examine the patients because the treatments of anaphylaxis and myocardial ischemia differs. Physicians should be alert to the risk of myocardial ischemia after treatment of anaphylaxis, especially following epinephrine administration.
       
  • A case report on the crashing eclamptic patient and a resulting
           peri-mortem C-section
    • Abstract: Publication date: Available online 18 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Sean Hickey, Marti Soffer, David Cherkas, Andrew Ditchik, Brenda BelooseskyAbstractBackgroundCardiac arrest in pregnancy is high acuity, low occurrence event. It involves the coordination of multiple teams to take care of ultimately two patients. This is further compounded by physiology that is frequently unfamiliar to the providers taking care of the patient.Case reportThis case report will detail sudden onset eclampsia in a patient whose condition deteriorated rapidly into cardiac arrest. It will delve into the complexities of managing this complex disease process and how the multi-disciplinary team quickly integrated to manage both the mother and the baby.Why should the emergency physician be aware of this': Cardiac arrest in pregnancy is an incredibly difficult situation due to both the physiological differences in the pregnant woman and the emotional factors on the treating providers (1). Due to its rarity, the pregnant cardiac arrest situation should be frequently reviewed to ensure appropriate care when the time arrives.The per-mortem c-section for a woman in cardiac arrest is a critical resuscitation technique that must be understood by providers who take care of critically ill patients ranging from emergency medicine to obstetrics and gynecology (Ob/Gyn) clinicians.
       
  • Is the flow-safe disposable continuous positive airway pressure (CPAP)
           system as effective as non-invasive mechanical ventilation (NIMV) in the
           treatment of acute cardiogenic pulmonary Oedema'
    • Abstract: Publication date: Available online 18 January 2020Source: The American Journal of Emergency MedicineAuthor(s): U.Z. İlhan, Güçlü Selahattin KIYAN, Enver ÖZÇETE, Sercan YALÇINLI, Mehmet Birkan KORGAN, Yusuf Ali ALTUNCI, Murat ERSEL, Funda Karbek AKARCA, Oğuz YAVUZGİL
       
  • The role of plasmapheresis in the treatment of
           hypertriglyceridemia-induced acute pancreatitis
    • Abstract: Publication date: Available online 18 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Kamil Kokulu, Serdar Özdemir, Abdullah Algın, Hatice Şeyma Akça
       
  • In reply to MS 22060 - Diagnosis of extrapulmonary tuberculosis and
           avoiding anchoring bias
    • Abstract: Publication date: Available online 17 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Brit Long, Stephen Y. Liang, Alex Koyfman, Michael Gottlieb
       
  • Complication of otitis media leads to opisthotonos in a toddler
    • Abstract: Publication date: Available online 17 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Samantha B. Esposito, Andrew H.F. Miller, Roy Rajan, Tibisay Villalobos, Susan K. YaegerAbstractOpisthotonos, extreme involuntary neck and back extension, is rarely seen in modern emergency departments. Vaccines have prevented the most common causes of this clinical presentation. Alternatively, otitis media is one of the most common pediatric infections and is characteristically non-invasive and harmless. In exceedingly rare cases, otitis media can develop complications and progress to invasive pneumococcal diseases including mastoiditis and meningitis. Streptococcus pneumoniae accounts for the majority of otitis media infections, however, since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) and 13-valent pneumococcal conjugate vaccine (PCV13) otitis media and its complications have decreased significantly. The present case reports of a previously healthy and immunized child presenting to a pediatric emergency department (PED) with opisthotonos, and was found to have pneumococcal meningitis, bacteremia and mastoiditis arising from otitis media.
       
  • Medicaid expansion and resource utilization in the emergency department
    • Abstract: Publication date: Available online 17 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Alexander T. Janke, Shooshan Danagoulian, Arjun K. Venkatesh, Phillip D. LevyAbstractBackgroundThe Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear.MethodsThis was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant.ResultsA total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051–1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144–1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983–1.229]).ConclusionMedicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.
       
  • Novel tube thoracostomy device reduces incision length
    • Abstract: Publication date: Available online 17 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Christopher Falslev, Shannon N. Thompson, Daniela Feldhausen
       
  • Diagnosis of aortic dissection by transesophageal echocardiography during
           cardiopulmonary resuscitation
    • Abstract: Publication date: Available online 16 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Yong Won Kim, Woo Jin Jung, Kyoung-Chul Cha, Young-Il Roh, Yoon-seop Kim, Oh. Hyun Kim, Yong Sung Cha, Hyun Kim, Kang Hyun Lee, Sung Oh. HwangAbstractObjectivesEarly identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest.MethodsAdult patients aged>20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups.ResultsForty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001–0.750; p = .035).ConclusionTEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.
       
  • Brief overview of Pentraxin 3
    • Abstract: Publication date: Available online 16 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Jun Zhang, Haili Wang, Boming Xia, Lun Dong
       
  • Treatment of migraine attacks by transcutaneous electrical nerve
           stimulation in emergency department: A randomize controlled trial
    • Abstract: Publication date: Available online 15 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Nihat M. Hokenek, Mehmet O. Erdogan, Ummahan Dalkilinc Hokenek, Abdullah Algin, Davut Tekyol, Avni U. SeyhanAbstractPurposeThe primary purpose of this trial is to evaluate the effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) therapy application in the emergency department.MethodsThe patients were divided into 2 groups: a sham group, and a verum group. Patients in the verum group include those who use the device for the first time. Both groups were connected to visually indistinguishable devices. Both groups underwent therapy for a total of 20 min. Using the Visual Analog Scale (VAS), the patients' perceived changes in pain intensity were recorded at the 20th and 120th minutes after initiation therapy. After the 120th minute, patients' individual needs for additional treatment were assessed. Additionally, their self-reported well-being was assessed using a Likert-type verbal scale.ResultsIn total 151 patients that were admitted to the emergency ward were assessed, with the sham and verum group being assigned 39 patients each from this pool. For the verum group the VAS change from 0 to 120 min was −65 ± 25 and for the sham group it was −9 ± 2 (p 
       
  • Risk factors for aortic dissection in patients aged <40
    • Abstract: Publication date: Available online 11 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Oscar M.P. Jolobe
       
  • Association between the NACA score and clinical outcomes
    • Abstract: Publication date: Available online 10 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Fabrice Dami, Vincent Darioli, Mathieu Pasquier
       
  • The rise of non-traumatic extremity compartment syndrome in light of the
           opioid epidemic
    • Abstract: Publication date: Available online 10 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Clifford C. Sheckter, Urska Cebron, Paola Suarez, Danielle Rochlin, Dario Tedesco, Tina Hernandez-Boussard, Catherine Curtin
       
  • Oxidative storm in a patient with acute rotenone-containing plant
           poisoning
    • Abstract: Publication date: Available online 9 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Jiun-Hao Yu, Chun-Fa Huang, Te-Hao Wang, Dong-Zong Hung, Han-Wei Mu, Chi-Syuan PanAbstractA 64-year-old woman presented with coma, seizure, and lactic acidosis after ingesting 80 yam bean seeds. This rotenone-containing seeds cause cellular asphyxia via blockage of the mitochondrial electron transport. Subsequent oxidative stress results in the formation of lipid peroxidation (LPO). Rotenone analysis via liquid chromatography mass spectrometry revealed the following: 31,590 ng/mL in cooked yam bean seed and 100 ng/mL in the blood. We attempted to use N-acetylcysteine to alleviate oxidative stress and documented the continuous decline in the plasma concentration of LPO.
       
  • Meropenem as an antidote for intentional valproic acid overdose: A case
           report
    • Abstract: Publication date: Available online 8 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Caitlin Thomas, James Priano, Tracey L. SmithAbstractValproic acid (VPA) is a broad-spectrum antiepileptic drug indicated for monotherapy and adjunctive therapy of seizures, and complex manic episodes associated with bipolar disorder [1]. While uncommon due to monitoring, VPA can cause toxicity at supratherapeutic levels [1, 2]. Traditional treatment for VPA toxicity is primarily supportive care, however activated charcoal, l-carnitine, and hemodialysis have been successful in removing free VPA [2]. An interaction between carbapenem antibiotics and VPA is well-established and listed in respective package inserts as a combination to be avoided due to decreased VPA efficacy [1, 3]. Recent literature suggests co-administration of meropenem with VPA reduces mean plasma VPA levels by 50–80% [4, 6]. This case report describes the successful use of carbapenems to intentionally lower toxic VPA levels in a 42 year old female that presented to the emergency department with VPA toxicity from an overdose with divalproex sodium.
       
  • Change in T/QRS ratio can be a supplementary diagnostic tool in predicting
           coronary artery disease in patients with NSTEMI
    • Abstract: Publication date: Available online 8 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Yuri Choi, Jae Hoon Lee, Jung In SeoAbstractBackgroundChanges in the electrocardiographic findings, namely the ratio T sum to QRS sum (T/QRS ratio), between the initial electrocardiogram (ECG) and the baseline ECG have rarely been investigated in patients with non-ST elevation myocardial infarction (NSTEMI). Thus, we aimed to determine whether changes in various parameters on ECG, including T/QRS ratio, can assist in distinguishing between coronary artery disease (CAD) and NSTEMI without CAD with low to moderate risk.MethodsThis retrospective study enrolled 2572 patients who presented ischemic symptoms, who were diagnosed with NSTEMI, and who underwent coronary angiography. Overall, 388 patients had prior ECG and echocardiography data available; 110 patients were included after excluding patients with other cardiac diseases except CAD. The population divided into two groups: a coronary stenosis group (n = 78); normal coronary group (n = 32) were analyzed.ResultsWe found that acute dynamic change in the most deviated T/QRS ratio in each region of leads of initial ECG from those of remote/recent ECG was an extremely strong predictor of acute CAD (odds ratio, 110; p  1.5 or
       
  • Intrathecal bupivacaine and morphine toxicity leading to transient
           hypotension and delayed status epilepticus
    • Abstract: Publication date: Available online 8 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Alexander M. Sidlak, Joseph H. Yanta, Michael J. LynchAbstractBackgroundLocal anesthetic systemic toxicity characteristically occurs after inadvertent intravascular injection of local anesthetics; however it is unclear if similar symptoms arise after intrathecal adminstration. Intrathecal use of local anesthetics for chronic pain is increasing and carries a potential risk of toxicity. Experience with the presenting symptoms and appropriate treatment for intrathecal local anesthetic toxicity is limited.Case studyA 74-year-old woman with an intrathecal bupivacaine/morphine pump developed lower extremity sensory neuropathy followed by obtundation, hypotension, and lower extremity flaccidity after an intrathecal pump refill. Her condition evolved to status epilepticus (SE) refractory to standard treatment. Intravenous fat emulsion (IFE) was administered, but was not immediately effective thus necessitating phenobarbital loading and propofol infusion. Despite significant bupivacaine neurotoxicity, no cardiotoxicity developed.DiscussionThe patient developed intrathecal local anesthetic and opioid toxicity after a malfunction of her intrathecal pump during a refill. We hypothesize that no cardiotoxicity developed secondary to sequestration of bupivacaine within the central nervous system. Likewise, poor CNS penetration of intravenous lipid emulsion may have negated or delayed any antidotal effect.ConclusionWe present a case of intrathecal toxicity leading to prolonged spinal anesthesia, progressive encephalopathy, and SE refractory to intravenous lipid emulsion. Management of SE with benzodiazepines and barbiturates may be more effective than lipids in cases of toxicity from intrathecal administration of bupivacaine.
       
  • Evaluation of corrosive poisoning in adult patients
    • Abstract: Publication date: Available online 8 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Selen Acehan, Salim Satar, Muge Gulen, Akkan AvcıAbstractObjectiveTo evaluate the demographic characteristics, endoscopy results, emerging complications and the final status of caustic intake cases admitted to our emergency department.MethodThis study is a retrospective one concerning patients admitted to our emergency department due to caustic ingestion. Demographic characteristics of the patients, complaints while applying to the hospital, physical examination findings, the purpose of caustic intake, the characteristics of corrosive substance taken, times of endoscopy following admission to the emergency department, follow-up times in the emergency department, endoscopic staging and outcome. The data were analyzed through IBM SPSS Statistics Base 22.0 package program.ResultsSeventy four patients participated in the study. 83.8% of corrosive substance intake cases were accidental and 16.2% cases were suicidal intention. While 60.8% of the corrosive substances taken had alkaline property, 36.5% were acidic and 2.7% were found to be unknown substances. 50% of the corrosive substance intakes were sodium hypochlorite. It was seen that endoscopy was performed in 59 patients who accepted endoscopy within an average of 244.07 min after admission to the emergency department. While no damage could be seen in 55.9% of patients following endoscopy, the most common injury was Grade 1 (35.6%).ConclusionCorrosive substance intake is a rare but potentially devastating poisoning with high morbidity and mortality. Mucosal injury begins within minutes following corrosive intake. Therefore, early endoscopy is helpful in assessing the degree of injury and early discharge from hospital.
       
  • History of appendectomy' An atypical case of recurrent abdominal pain
    • Abstract: Publication date: Available online 7 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Kei Wong, Doruk E. Ozgediz, James DodingtonAbstractAcute appendicitis is a common condition emergency physician encounter during pediatric emergency visits. With a reported incidence of 1 in 50,000 appendectomies, stump appendicitis, an acute inflammation of the residual appendicular tissue, is a rare post-operative complication. The diagnosis of stump appendicitis is time-critical to prevent associated morbidities of abscess formation, perforation and sepsis. Another atypical presentation of appendicitis includes recurrent appendicitis, which is recognized as one or more previous episodes of similar clinical presentation as acute appendicitis, but symptoms subside within 24 to 48 h. Intervals between attacks may vary from weeks to years during which the patient may be asymptomatic. Although recurrent appendicitis is rare, emergency physicians should be aware of this possibility and to not assume that previous appendectomy precludes recurrent appendicitis. This case highlights the importance of considering such unusual condition in a patient presenting with recurrent right-sided abdominal pain.
       
  • Emergency department evaluation of patients with angiotensin converting
           enzyme inhibitor associated angioedema
    • Abstract: Publication date: Available online 7 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Philip A. Mudd, Edmond A. Hooker, Uwe Stolz, Kimberly W. Hart, Jonathan A. Bernstein, Joseph J. MoellmanAbstractIntroductionAngiotensin converting enzyme inhibitor (ACEi) associated angioedema is frequently encountered in the emergency department. Airway management is the primary treatment, but published evidence supporting the decision to intubate patients with this condition is extremely limited.MethodWe performed a retrospective study of all cases of ACEi associated angioedema encountered in a large, urban, tertiary referral emergency department. We classified demographics, duration of symptoms before presentation, physical exam findings and nasopharyngoscopy findings in patients that did and did not require intubation.ResultsWe identified a total of 190 separate encounters from 183 unique patients who presented during the 3-year period of the study. Eighteen (9.5%) of these patients required intubation. Patients requiring intubation were more likely to present within 6 h of the onset of angioedema symptoms. Anterior tongue swelling, vocal changes, drooling, and dyspnea were significantly more common in patients requiring intubation. Isolated lip swelling was present in 54% of all patients and was the only finding significantly more common in the group that did not require intubation.ConclusionsRapid progression of symptoms within the first 6 h of angioedema onset, anterior tongue swelling, vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema. Isolated lip swelling is significantly more common in patients that do not require intubation. Our data provide risk stratification guidance for providers treating patients with suspected ACEi associated angioedema in the emergency department.
       
  • Collegiate EMS providers' role in vaping education
    • Abstract: Publication date: Available online 7 January 2020Source: The American Journal of Emergency MedicineAuthor(s): Christopher Gaeta
       
  • Inhaled TXA for cases of massive hemoptysis
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Tori R. Adams, Jacob A. Reeder, Fuad Alqassab, Brian W. Gilbert
       
  • Enhancing early response to out-of-hospital cardiac arrest
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Ziv Dadon, Evan Avraham Alpert, Eli Jaffe
       
  • Stop the stereotypes – Women should not have to prove their
           non-inferiority
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Sarah Morton, Pascale Avery
       
  • Letter to the editor
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Eve Purdy, Samantha A Batt-Rawden, Jae Won Joh, S. Luckett-Gatopoulos, Alim Pardhan, Saroo Sharda, Menaka Pai
       
  • A word for equity: the long road ahead
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Laura Lorenzon, Gaya Spolverato, Isabella Frigerio, Domenico D'Ugo
       
  • On first-pass, twitter response is inferior to expectations
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): K. Ogle, C. Roche, A. Pourmand
       
  • Emergency medicine research and gender: Sensitivity and censorship
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): J. Douglas White
       
  • Evaluation and management of cauda equina syndrome in the emergency
           department
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Brit Long, Alex Koyfman, Michael GottliebAbstractBackgroundCauda equina syndrome (CES) may be a devastating disease with the potential for significant patient morbidity. It is essential for emergency clinicians to be aware of how to effectively diagnose and manage this condition.ObjectiveThis article provides a narrative review of the diagnosis and management of CES for the emergency clinician.DiscussionCauda equina syndrome is a rare but emergent condition associated with back pain. It can result in severe morbidity and can be due to a variety of causes, most commonly vertebral disc protrusion. Diagnosis is often delayed, which may result in a poor prognosis. Red flags and findings consistent with CES include bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function leading to painless urinary retention, loss of anal tone, and loss of sexual function. In isolation, history and examination findings demonstrate poor sensitivity. Symptoms may occur either suddenly or gradually, and most patients do not present with all of these symptoms. Postvoid bladder volume assessments can assist in the evaluation, but the diagnosis typically involves magnetic resonance imaging (MRI) or computed tomography myelography if MRI is not available. Treatment relies upon surgical consultation and operative intervention for decompression.ConclusionCauda equina syndrome can be a difficult diagnosis. However, knowledge of the history and examination findings, imaging, and treatment can assist the emergency clinician in optimizing management of this condition.
       
  • Compensation models in emergency medicine: An ethical perspective
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Daniel R. Martin, John C. Moskop, Kelly Bookman, Jesse B. Basford, Joel Martin GeidermanAbstractThere is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.
       
  • Role of high-dose intravenous nitrates in hypertensive acute heart failure
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Kellie Wang, Kathryn SamaiAbstractBackgroundPatients with hypertensive acute heart failure (H-AHF) can decompensate rapidly and require immediate medical attention; the use of high-dose nitroglycerin is a topic of growing interest in this patient population.Objective of the reviewThe purpose of this review is to provide an evidence-based approach for the utilization of high-dose nitrates in the emergent management of H-AHF.DiscussionTwo randomized controlled trials, three prospective studies, two retrospective cohorts, two case series, and one case report were evaluated. Level of robust evidence and heterogeneity limit the ability to draw strong conclusions regarding the use of high-dose nitrates. Despite these limitations, high-dose nitrates appeared to have an overall beneficial effect across all studies reviewed, including lower rates of mechanical ventilation, improvement in blood pressure, shorter LOS, and lower rates of ICU admission. Adverse effects were mild and infrequently reported.ConclusionsHigh-dose nitrates are likely safe and may be effective, as demonstrated in the studies reviewed. High-dose NTG may be appropriate in H-AHF patients presenting with severe respiratory distress and SBP ≥160 mmHg or MAP ≥120 mmHg. Future well-designed randomized controlled trials are needed to elucidate optimal dosing strategies and confirm safety and efficacy of high-dose nitrates.
       
  • A randomized trial of ultrasound-guided peripheral IV catheter placement
           in difficult access patients using a guidewire approach
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Haley K. Cochrane, Patricia C. Henwood, Elke Platz, Viktoria Koskenoja, Adaira Landry, Sarah E. Frasure, Joshua S. Rempell, Janet Hoyler, Olesya Baker, Heidi H. KimberlyAbstractObjectiveThe purpose of this pilot study was to investigate whether use of a guidewire improves successful placement of ultrasound-guided peripheral IVs (PIV) in difficult intravenous access patients in the emergency department (ED).MethodsThis was an unblinded, prospective, randomized trial performed by emergency medicine (EM) clinicians at a single academic ED. Eligible participants were randomized to ultrasound-guided PIV placement with or without the use of a guidewire. PIV access was obtained using the Accucath™ 20 gauge × 5.7 cm catheters by way of deployment or non-deployment of the guidewire. Primary outcome measure was first-pass success rate and secondary outcomes included number of attempts, complication rates, and clinician reported ease of insertion.ResultsSeventy patients were enrolled and 69 were included in the final analysis. Thirty-four participants were randomized to use of guidewire and 35 to no guidewire. First-pass success rates were similar with and without guidewire use, 47.1% vs. 45.7%, (p = 0.9). There were no differences found in median number of attempts between the two techniques, 2 (IQR 1–2) vs 2 (IQR 1–2), (p = 0.60). The complication rates were similar, 15% vs. 29% (p = 0.25). Clinicians reported no difference in ease of insertion between methods on a 5-point Likert Scale, mean 2.6 vs 2.7 (p = 0.76).DiscussionIn this pilot study comparing ultrasound-guided PIV placement in ED patients using an integrated guidewire versus no guidewire, there was no significant difference in first-pass success, number of attempts, or complication rates. This study provides preliminary data for further investigations.
       
  • Pedometer-measured physical activity among emergency physicians during
           shifts
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Gregory A. Peters, Matthew L. Wong, Leon D. SanchezAbstractObjectiveTools to measure physical activity, such as pedometers, have become more prevalent and attracted popular interest in recent years. Despite this trend, research has not yet quantified pedometer-measured physical activity among Emergency Physicians. This study aims to provide the first characterization of physical activity among on-duty Emergency Physicians in terms of step count.MethodsEmergency Physicians wore Empatica E4 research-grade accelerometers while performing routine clinical care in the Emergency Department. A publicly available algorithm was used to estimate the number of steps taken.ResultsFifty-one Emergency Physicians, including thirty-four residents and seventeen attending physicians, contributed over 1500 h of accelerometer data. On average, this cohort took 577 steps per hour (SD: 72.6), totaling 4950 steps per recorded shift (SD: 737.8), which is approximately 2.6 miles (SD: 0.31). Residents walked more than attending physicians (595.9 steps per hour (SD: 99.7) vs 563.0 steps per hour (SD: 89.0), respectively; p = 0.02).ConclusionThe average emergency physician in this cohort walked roughly half the daily recommended number of steps during their recorded shift. Residents walk significantly more than attending physicians.
       
  • Implementation of a pilot electronic stroke outcome reporting system for
           emergency care providers
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): William L. Scheving, Joseph M. Ebersole, Michael Froehler, Donald Moore, Kiersten Brown-Espaillat, James Closser, Wesley H. Self, Michael J. WardAbstractIntroductionEmergency department (ED) providers and clinicians find that feedback on acute stroke patients is rewarding, valuable to professional development, and helpful for practice improvement. However, feedback is rarely provided, particularly for patients with stroke. Here we describe the implementation of an electronic stroke outcome reporting tool for providing feedback to ED providers.MethodsWe sought to evaluate the implementation of an electronic stroke outcome reporting tool at 3 Nashville hospitals. ED staff and providers voluntarily enrolled to receive de-identified reports of clinical (e.g., survival) and operational (e.g., timeliness) outcomes of patients with acute ischemic stroke and were offered free continuing education (CE) credits for following up on patients. We evaluated the implementation of this system through a descriptive evaluation of the feasibility, use of the system and CE, and perceived usefulness of the reports.ResultsWe enrolled 232 ED providers, including 107 (46%) nurses and 57 (25%) attending physicians and transmitted 55 stroke outcome reports. Reports took 30–60 min to compile and were viewed by a mean of 2.6 (SD 1.5) registered providers; 97.1% found the reports useful and 36.2% reported likelihood to change practice. Continuing education credits were initiated or claimed by 22 providers.ConclusionsAn electronic stroke outcome reporting tool was used and liked by ED staff and providers but the time to compile the reports is the major challenge to scalability. Future research should address the effectiveness of this reporting tool as a source of provider education and its impact on clinical and operational outcomes.
       
  • Can physicians detect hyperkalemia based on the electrocardiogram'
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Zubaid Rafique, Jorge Aceves, Ilse Espina, Frank Peacock, David Sheikh-Hamad, Dick KuoAbstractObjectiveAlthough there is no consensus on how to use an electrocardiogram (ECG) in patients with hyperkalemia, physicians often obtain it in the acute setting when diagnosing and treating hyperkalemia.The objective of this study is to evaluate if physicians are able to detect hyperkalemia based on the ECG.MethodsThe study was conducted at a large county hospital with a population of end stage renal disease (ESRD) patients who received hemodialysis (HD) solely on an emergent basis. Five hundred twenty eight ECGs from ESRD patients were evaluated. The prevalence of hyperkalemia was approximately 60% in this cohort, with at least half of them in the severe hyperkalemia range (K ≥ 6.5 mEq/L).ResultsThe mean sensitivity and specificity of the emergency physicians detecting hyperkalemia were 0.19 (± 0.16) and 0.97(± 0.04) respectively. The mean positive predictive value of evaluators for detecting hyperkalemia was 0.92 (±0.13) and the mean negative predictive value was 0.46 (± 0.05). In severe hyperkalemia (K ≥ 6.5 mEq/L), the mean sensitivity improved to 0.29 (± 0.20), while specificity decreased to 0.95 (±0.07).ConclusionAn ECG is not a sensitive method of detecting hyperkalemia and should not be relied upon to rule it out. However, the ECG has a high specificity for detecting hyperkalemia and could be used as a rule in test.
       
  • Plasma oxidative-stress parameters and prolidase activity in patients with
           various causes of abdominal pain
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Levent Albayrak, Ozgur Sogut, Sümeyye Çakmak, Mehmet Tahir Gökdemir, Halil KayaAbstractPurposeWe aimed to investigate the predictive power of plasma prolidase activity and oxidative-stress parameters for distinguishing in patients with various causes of non-traumatic abdominal pain who presented to the emergency department.MethodsThis study enrolled 100 consecutive adult patients and 100 age- and sex-matched healthy controls. The patients were divided into surgically treated patients (STP); medically treated patients (MTP) and nonspecific abdominal pain (NSAP) patients. As predictors of early oxidative changes, the plasma prolidase activity, total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI) were assessed using a novel automated method.ResultsNo significant difference was observed between the patients and the controls with respect to age or sex (p = 0.837 and 0.188, respectively). The plasma TOS, OSI value, and prolidase activity were significantly higher in the patients with abdominal pain than in the controls (p 
       
  • The difference of subcutaneous digital nerve block method efficacy
           according to injection location
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Sungwoo Choi, Young Soon Cho, Bora Kang, Gi Woon Kim, Sangsoo HanAbstractIntroductionFinger injuries are commonly attended to in the emergency department, and digital nerve block is a frequently performed procedure for such injuries. This study compared the efficacy levels of the subcutaneous method according to the different injection sites.MethodThis was a simulation study for medical students who rendered medical service at the emergency department. One group performed subcutaneous injection of lidocaine at the volar side of the metacarpophalangeal (MCP) joint, while another group injected at the volar side of the proximal interphalangeal (PIP) joint. The time to anesthesia was measured at 30-s intervals. Pain at the injection site was measured using the numeric rating scale (NRS), while the length from the fingertip to the injection site and the circumference of the injection site were measured.ResultsA total of 82 participants were included, with 41 under the MCP joint group and the rest under the PIP joint group. The mean length from the fingertip to the needling point was 3.62 ± 0.63 cm in the PIP joint group and 5.90 ± 0.65 cm in the MCP joint group, while the mean circumference of the needling point was 4.93 ± 0.51 and 5.61 ± 0.58 cm, and the mean time to anesthesia was 2.55 ± 1.11 and 3.79 ± 1.28 min (p-value 
       
  • Distinct subgroups of emergency department frequent users: A latent class
           analysis
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Lauren E. Birmingham, Vinay K. Cheruvu, Jennifer A. Frey, Kirk A. Stiffler, Jonathan VanGeestAbstractBackgroundEmergency department (ED) frequent users have high resource utilization and associated costs. Many interventions have been designed to reduce utilization, but few have proved effective. This may be because this group is more heterogeneous than initially assumed, limiting the effectiveness of targeted interventions. The purpose of this study was to identify and describe distinct subgroups of ED frequent users and to estimate costs to provide hospital-based care to each group.MethodsLatent class analysis was used to identify homogeneous subgroups of ED frequent users. ED frequent users (n = 5731) from a single urban tertiary hospital-based ED and level 1 trauma center in 2014 were included. Descriptive statistics (counts and percentages) are described to characterize subgroups. A cost analysis was performed to examine differences in direct medical costs between subgroups from the healthcare provider perspective.ResultsFour subgroups were identified and characterized: Short-term ED Frequent Users, Heart-related ED Frequent Users, Long-term ED Frequent Users, and Minor Care ED Frequent Users. The Heart-related group had the largest per person costs and the Long-term group had the largest total group costs.ConclusionDistinct subgroups of ED frequent users were identified and described using a statistically objective method. This taxonomy of ED frequent users allows healthcare organizations to tailor interventions to specific subgroups of ED frequent users who can be targeted with tailored interventions. Cost data suggest intervention for long-term ED frequent users offers the greatest cost-avoidance benefit from a hospital perspective.
       
  • Effect of infarct site on the clinical endpoints of thrombolytic-treated
           ST-elevation myocardial infarction
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Kristina Gifft, Mary Dohrmann, Mohammad Eniezat, Tariq EnezateAbstractIntroductionSome studies suggest better outcomes after the use of thrombolytics in inferior ST-elevation myocardial infarction (STEMI) compared to other locations. The goal of this study is to compare the clinical endpoints of thrombolytic-treated STEMI based on coronary artery distribution.MethodsThe study population was extracted from the 2014 Nationwide Readmissions Data using the International Classification of Diseases, Ninth Revision, Clinical Modifications codes for STEMI, thrombolytic infusion, and complications of STEMI. Primary study endpoints included in-hospital all-cause mortality, length of hospital stay (LOS), cardiogenic shock, and mechanical complications of STEMI.ResultsA principal diagnosis of thrombolytic-treated STEMI was identified for in 1231 patients (mean age 61.5 years; 26.5% female). Four hundred and thirty-one STEMIs occurred in the left anterior descending (LAD) artery distribution, 124 in the left circumflex (LCX) artery distribution, and 676 in the right coronary artery (RCA) distribution. In comparison to the LAD and LCX distributions, thrombolytic-treated STEMIs in the RCA distribution were associated with lower mortality (6.5% with LAD, 5.7% with LCX, and 3.6% with RCA; p = 0.02), fewer cardiogenic shock (12.3% with LAD, 12.1% with LCX, and 7.7% with RCA; p = 0.01), and shorter LOS (4.5 days with LAD, 3.9 with LCX, and 3.6 days with RCA; p 
       
  • Quality retention of chest compression after repetitive practices with or
           without feedback devices: A randomized manikin study
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Xian-Long Zhou, Jing Wang, Xiao-Qing Jin, Yan Zhao, Rui-Ling Liu, Cheng JiangAbstractObjectivesThis study was designed to investigate whether an audiovisual feedback (AVF) device is beneficial for quality retention of chest compression (CC) after repetitive practices (RP).MethodsAfter completion of a 45-min CC-only cardiopulmonary resuscitation (CPR) training, participants performed 3 sessions of practices on days 1, 3, and 7 under the guidance of an instructor with (RP + AVF) or without (RP) the AVF device. CC quality was determined after each session and was retested at 3 and 12 months.ResultsIn total, ninety-seven third year university students participated in this study. CC quality was improved after 3 sessions in both the RP and RP + AVF groups. Retests at 3 months showed that the proportions of appropriate CC rate and correct hand position were significantly decreased in the RP group as compared with the last practice (p 
       
  • Cardiopulmonary resuscitation ameliorates myocardial mitochondrial
           dysfunction in a cardiac arrest rat model
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Wen Xu, Yue Fu, Longyuan Jiang, Zhengfei Yang, Yue Wang, Wanchun Tang, Xiangshao FangAbstractPurposePrevious studies implicate that the mitochondrial injury may play an important role in the development of post-resuscitation myocardial dysfunction, however few of them are available regarding the ultrastructural alterations of myocardial mitochondria, mitochondrial energy producing and utilization ability in the stage of arrest time (no-low) and resuscitation time (low-flow). This study aimed to observe the dynamic changes of myocardial mitochondrial function and metabolic disorders during cardiac arrest (CA) and following cardiopulmonary resuscitation (CPR).MethodsA total of 30 healthy male Sprague-Dawley rats were randomized into three groups: 1) VF/CPR: Ventricular fibrillation (VF) was electrically induced, and 5 min of CPR was performed after 10 min of untreated VF; 2) Untreated VF: VF was induced and untreated for 15 min; and 3) Sham: Rats were identically prepared without VF/CPR. Amplitude spectrum area (AMSA) at VF 5, 10 and 15 min were calculated from ECG signals. The rats' hearts were quickly removed at the predetermined time of 15 min after beginning the procedure to gather measurements of myocardial mitochondrial function, high-energy phosphate stores, lactate, mitochondrial ultrastructure, and myocardial glycogen.ResultsThe mitochondrial respiratory control ratios significantly decreased after CA compared to sham group. CPR significantly increased respiratory control ratios compared with untreated VF animals. A significant decrease of myocardial glycogen was observed after CA, and a more rapid depletion of myocardial glycogen was observed in CPR animals. CPR significantly reduced the tissue lactate. The mitochondrial ultrastructure abnormalities in CPR animals were less severe than untreated VF animals. AMSA decayed during untreated VF; however, it was significantly greater in CPR group than the untreated VF group. In addition, AMSA was clearly positively correlated with ATP, but negatively correlated with myocardial glycogen.ConclusionImpairment of myocardial mitochondrial function and the incapability of utilizing glycogen were observed after CA. Furthermore, optimal CPR might, in part, preserved mitochondrial function and enhanced utilization of myocardial glycogen.
       
  • Effects of 20-degree spinal immobilization on respiratory functions in
           otherwise healthy volunteers with android-type obesity
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Gülşah Çıkrıkçı Işık, Osman Lütfi Demirci, Şeref Kerem Çorbacıoğlu, Yunsur ÇevikAbstractAimThe aim of the study was to assess whether spinal immobilization with long back board (LBB) and semi-rigid cervical collar (CC) at 20° instead of 0° conserves pulmonary functions in obese volunteers, including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio.MethodsThe study included adult volunteer subjects with android-type obesity who were otherwise healthy. First, pulmonary functions were tested in a seated position to obtain baseline levels, than volunteers were immobilized with LBB and CC at 0-degree and measurements repeated at 0th and 30th minute of immobilization. Next day, same procedures were repeated with the trauma board at 20-degree. Changes over time in FEV1, FVC values and FEV1/FVC ratios during spinal immobilization at 0° and 20° were compared to baseline levels.ResultsStudy included 30 volunteers. Results showed a significant decline in all values for both situations following spinal immobilization (p  .05).ConclusionThe present findings confirm that spinal immobilization reduces pulmonary functions in obese volunteers, and that 20-degree immobilization has no conservative effect on these values when compared to the traditional 0-degree immobilization. It may be that 20° is insufficient to decrease the negative effect of abdominal obesity on pulmonary functions.
       
  • Accuracy of patient self-administered medication history forms in the
           emergency department
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Angela Wai, Martina Salib, Sohileh Aran, James Edwards, Asad E. PatanwalaAbstractObjectivesThe primary objective of this study was to determine the proportion of patients with medication discrepancies when using a self-administered medication history form in the emergency department (ED). The secondary objectives were to identify predictors of medication discrepancies and determine the proportion of patients with a high-risk medication discrepancy.MethodsThis was a cross-sectional study conducted in an urban ED in Australia. Patients completed a self-administered medication history form while waiting to be seen by a physician. Subsequently, a best possible medication history was taken by a pharmacist to determine accuracy of the self-reported medication lists for patients with planned admissions. Discrepancies between the two medication lists were reported descriptively. A Poisson regression analysis was conducted to identify predictors of the rate of discrepancies. Associations were reported as incident rate ratios (IRR).ResultsA total of 138 patients were included in the study. The total number of discrepancies was as follows: 0 (25%, n = 34), 1 (34%, n = 47), 2 (11%, n = 15), and ≥3 (30%, n = 42). The number of medications (IRR 1.11, 95% CI 1.09 to 1.14, p 
       
  • Developing neural network models for early detection of cardiac arrest in
           emergency department
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Dong-Hyun Jang, Joonghee Kim, You Hwan Jo, Jae Hyuk Lee, Ji Eun Hwang, Seung Min Park, Dong Keon Lee, Inwon Park, Doyun Kim, Hyunglan ChangAbstractBackgroundAutomated surveillance for cardiac arrests would be useful in overcrowded emergency departments. The purpose of this study is to develop and test artificial neural network (ANN) classifiers for early detection of patients at risk of cardiac arrest in emergency departments.MethodsThis is a single-center electronic health record (EHR)-based study. The primary outcome was the development of cardiac arrest within 24 h after prediction. Three ANN models were trained: multilayer perceptron (MLP), long-short-term memory (LSTM), and hybrid. These were compared to other classifiers including the modified early warning score (MEWS), logistic regression, and random forest. We used AUROC, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the comparison.ResultsDuring the study period, there were a total of 374,605 ED visits and 2,910,321 patient status updates. The ANN models (MLP, LSTM, and hybrid) achieved higher AUROC (AUROC: 0.929, 0.933, and 0.936; 95% confidential interval: 0.926–0.932, 0.930–0.936, and 0.933–0.939, respectively) compared to the non-ANN models, and the hybrid model exhibited the best performance. The ANN classifiers displayed higher performance in most of the test characteristics when the threshold levels of the classifiers were fixed to display the same positive result as those at the three MEWS thresholds (score ≥ 3, ≥4, and ≥5), and when compared with each other.ConclusionsThe ANN improves upon MEWS and conventional machine learning algorithms for the prediction of cardiac arrests in emergency departments. The hybrid ANN model utilizing both baseline and sequence information achieved the best performance.
       
  • Intubation and intensive care after laminaria anaphylaxis in
           second-trimester abortion
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Miriam McQuade, Kyle Barbour, Sarah Betstadt, Amy HarringtonAbstractLaminaria are cervical dilators inserted for several days preceding second-trimester abortions and other uterine procedures. Our patient was intubated after a life-threatening anaphylactic reaction to laminaria prior to her surgical abortion. Abortions with laminaria dilators are frequently performed outpatient across the United States. Due to stigma, increasing restrictions, and forced closure of family planning clinics, these procedures are often obtained covertly and remotely. Patients may present obtunded, in shock, without records or proxy, and with no external evidence of the allergen's location or continued presence. Emergency and critical care physicians may consider this etiology in obtunded women with anaphylaxis who are responding poorly to standard care.
       
  • Berberine inhibits the ischemia-reperfusion induced testicular injury
           through decreasing oxidative stress
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Ilke Onur Kazaz, Ahmet Mentese, Selim Demir, Gokcen Kerimoglu, Fatih Colak, Akin Bodur, Ahmet Alver, Omer Kutlu, Suleyman TurediAbstractPurposeThe aim of this study was to investigate the effect of berberine (BBR) on oxidative stress in an experimental testicular I/R injury model.MethodsEighteen rats were divided into three groups: control group, torsion-detorsion (T/D) group, and BBR + T/D group. In the pre-treatment of the BBR group, 200 mg/kg BBR was given intraperitoneally 30 min before detorsion. Tissue malondialdehyde (MDA), total oxidant status (TOS), and total antioxidant status (TAS) levels were determined using colorimetric methods. Histological evaluation of the tissue samples was evaluated using hematoxylin-eosin staining.ResultsIn T/D group, tissue MDA, TOS, and oxidative stress index levels were higher than control group. These increases were significantly reversed with BBR pre-treatment. Although Johnsen scores were lower in T/D group than the control group, BBR pre-treatment recovered the Johnsen scores.ConclusionThese results suggest that BBR can inhibit I/R-induced testicular injury by suppressing oxidative stress. Further studies may prove that BBR is a useful agent as an adjunctive treatment in surgical repair in human cases.
       
  • Opioid free treatment algorithm for ED headache management: Effect on
           revisit rate
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Justin Miller, Laura Koons, Daniel LongyhoreAbstractBackgroundThe opioid epidemic is a crisis leading to over utilization of resources within emergency departments (EDs). We assessed how implementation of an opioid-free headache and migraine treatment algorithm in the ED impacted patient centered outcomes.MethodsThis was a retrospective review of patients presenting to EDs across a health network with a primary diagnosis of headache or migraine. Two analyses were completed comparing patients presenting before and after implementation of an opioid-free treatment algorithm and patients treated with or without opioids in the ED. The primary outcome was incidence of an ED revisit within thirty days. Secondary outcomes included ED length of stay, admission rate, and incidence of revisit during the entire study period.ResultsIn total, 2953 patient encounters were included. Incidence of revisit within thirty days was lower in the post- (84/1339, 6.3%) versus pre-algorithm group (133/1614, 8.2%; odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56–0.99; p = 0.049), as was the incidence of revisit within the entire study period (9.2% vs. 12.1%; OR 0.74, CI 0.58–0.93; p = 0.014). In the secondary analysis, patients treated with opioids had a higher incidence of revisit within thirty days (51/335, 15.2%) compared to those not treated with opioids (166/2618, 6.3%). The opioid group also had a higher incidence of admission rates and median ED length of stay.ConclusionsOpioid use in the ED to treat patients with headaches or migraines may have several negative ramifications including increased risk of revisit, hospital admission, and increased ED length of stay.
       
  • Epidemiology of opioid-related visits to US Emergency Departments,
           1999–2013: A retrospective study from the NHAMCS (National Hospital
           Ambulatory Medical Care Survey)
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Matthew Salzman, Christopher W. Jones, Rachel Rafeq, John Gaughan, Rachel HarozAbstractGoalsTo characterize the epidemiology of opioid-related visits to United States (US) emergency departments (EDs) and describe trends in opioid-related visits over time.DesignRetrospective cohort studyCasesThe National Hospital Ambulatory Care Survey (NHAMCS) was used to identify opioid-related ED visits between 1999 and 2013.MeasurementsThe NHAMCS is an annual, weighted, multi-stage survey which allows for the study of ambulatory care services within a nationally representative sample of US hospitals. We used ICD-9 codes to identify ED visits related to opioid use and abuse. We applied visit weights calculated by NHAMCS to generate nation-wide estimates regarding the overall prevalence of opioid-related visits, and demographic characteristics of these patients. We report trends with respect to opioid-related visits and ED resource utilization between 1999 and 2013.Results1072 visits were included, representing 2,731,000 nation-wide opioid-related ED encounters between 1999 and 2013. During this time, opioid-related ED visits increased from 125,000 in 1999 to over 300,000 visits in 2013. Between 1999–2001 and 2011–2013 opioid-related visits increased by 170%. Greater numbers of such visits occurred across nearly all demographic groups, and all regions of the US. Weighted visits among women increased by 250% between these time periods. Over these periods, opioid-related ED visits resulting in hospital admission increased by over 240%. The proportion of ED visits that were related to opioids doubled from 1999 (0.12%) to 2013 (0.25%).ConclusionsOpioid-related ED encounters and resource utilization both rose substantially between 1999 and 2013, with consistent increases across a broad spectrum of demographic groups.
       
  • A checklist manifesto: Can a checklist of common diagnoses improve
           accuracy in ECG interpretation'
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Jillian Nickerson, Emily S. Taub, Kaushal ShahAbstractObjectiveTo determine whether a checklist of possible etiologies for syncope provided alongside ECGs helps Emergency Medicine (EM) residents identify ECG patterns more accurately than with ECGs alone.MethodsWe developed a test of ten ECGs with syncope-related pathology from ECG Wave-Maven. We reviewed the literature and used expert consensus to develop a checklist of syncope-related pathologies commonly seen and diagnosed on ECGs. We randomized residents from three New York EM residency programs to interpret ECGs with or without a checklist embedded into the test.ResultsWe randomized 165 residents and received completed tests from 100 (60%). Of those who responded, 39% were interns, 23% PGY2s, and 38% were PGY3s or PGY4s. We found no significant difference in overall test scores between those who read ECGs with a checklist and those who read ECGs alone. In post-hoc analysis, residents given a checklist of syncoperelated etiologies were significantly more likely to recognize Brugada (96% vs. 78%, p = 0.007), long QT (86% vs. 68%, p = 0.03) and heart block (100% vs 78%, p = 0.003) as compared to those without a checklist. Those with a checklist were more likely to overread normal ECGs (72% vs 35%, p = 0.0001) compared to those without a checklist, finding pathology where there was none.ConclusionUsing a checklist with common syncope-related pathology when interpreting an ECG for a patient with clinical scenario of syncope may improve residents' ability to recognize some clinically important pathologies; however it could lead to increased interpretation and suspicion of pathology that is not present.
       
  • A new marker identification of high risk stroke patients: Jugular
           saturation
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Mevlut Guven, Nazire Belgin Akilli, Ramazan Koylu, Vefa Oner, Merve Guven, Muhammed Rasit OzerAbstractObjectivesThe aim of this prospective study; to investigate in emergency patients with stroke the relationship between jugular saturation and National Institutes of Health Stroke Scale (NIHSS), lesion volume and mortality score.Materials and methodsIn this prospective study, 82 patients who fulfilling the criteria for inclusion in diagnosed with were enrolled in the study. Patients' demographic data, comorbid conditions and stroke type were recorded. The arterial blood pressure, heart rate, and consciousness were recorded at the emergency department. Glasgow Coma Score (GCS) and National Health Institutions Stroke Scale (NIHSS) scores were calculated. Complete Blood Count (CBC) and biochemical values were obtained at the time of admission to the emergency department. Arterial blood gas and jugular venous blood gas were taken and pO2, SpO2 and lactate values were recorded. Patients were grouped according to jugular desaturation (
       
  • Interrater reliability of pediatric point-of-care lung ultrasound findings
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Cynthia A. Gravel, Michael C. Monuteaux, Jason A. Levy, Andrew F. Miller, Rebecca L. Vieira, Richard G. BachurAbstractObjectiveWe sought to assess interrater reliability (IRR) of lung point-of-care ultrasound (POCUS) findings among pediatric patients with suspected pneumonia.MethodsA convenience sample of patients between the ages of 6 months and 18 years with a clinical suspicion of pneumonia had a lung ultrasound performed by a POCUS-credentialed emergency medicine physician with subsequent expert review. Each lung zone was assessed as either normal or abnormal, and specific ultrasound findings were recorded. IRR was assessed by intraclass correlation coefficient (ICC) and kappa statistics.ResultsSeventy-one patients, with a total of 852 lung zones imaged, were included. The sonographer assessment of normal versus abnormal, across each of the zones, demonstrated moderate agreement with ICC 0.46 (95% CI: 0.41, 0.52) and kappa 0.56. Right-sided zones demonstrated moderate agreement [0.43 (CI 0.35, 0.51)] while left-sided zones, specifically left-sided anterior zones, showed only fair agreement [0.36 (0.28, 0.44)]. IRR varied between specific findings: ICC for B-lines 0.52 (95% CI: 0.46, 0.57), pleural effusion 0.40 (0.34, 0.45), consolidation 0.39 (0.33, 0.44), subpleural consolidation 0.31 (0.25, 0.37), and pleural line irregularity 0.16 (0.10, 0.23). A composite indicator of typical pneumonia findings (consolidation, B-lines, and pleural effusion) demonstrated moderate [ICC 0.52 (0.46, 0.57)] reliability.ConclusionsWe found moderate interrater reliability of lung POCUS findings for the assessment of pediatric patients with suspected pneumonia. B-lines had the highest reliability. Further assessment of lung POCUS is necessary to guide proper training and optimal scanning techniques to ensure adequate reliability of ultrasound findings in the assessment of pediatric pneumonia.
       
  • TOC
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s):
       
  • Massive emphysema after tooth extraction
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Yun Pan
       
  • Ultrasound-guided analgesic injection for acromioclavicular joint
           separation in the emergency department
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Carlos Mikell, Jonathan Gelber, Arun NagdevAbstractWe present the first documented case of an emergency clinician treating the pain of an acute Acromioclavicular (AC) joint separation through ultrasound (US) guided injection of an anesthetic agent. A 41 year old male presented with an acute traumatic grade III AC joint separation after falling off a scooter, and his pain was not significantly improved with oral medication. The AC joint was located by US, and bupivacaine was injected into the joint effusion under US guidance, yielding near complete resolution of pain. In orthopedics and physiatry literature, US guided AC joint injections have been shown to be far more efficacious than landmark guided AC joint injections, yet this is the first known case documenting injection in the Emergency Department (ED). The superficial location of the AC joint, its ease of identification by US, and the rapid onset of analgesia by intra-articular injection makes the US-guided anesthetic injection of the AC joint an ideal tool to incorporate into a multimodal approach to pain management in AC joint separations.
       
  • Intravenous potassium solution boluses save a life from hypokalemic
           cardiac arrest
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Jen-Kuei Liu, Shyh-Shyong Sim, Fu-Chien Hsieh, Yuan-Hui Wu
       
  • Discharges against medical advice from U.S. emergency departments
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Maher Kazimi, Joshua D. Niforatos, Justin A. Yax, Ali S. Raja
       
  • Tranexamic acid in traumatic hemorrhage: Evidence argues for a prehospital
           administration
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Mathieu Boutonnet, Gabriella Osorio Cajes, Pierre Pasquier, Sylvain Ausset
       
  • Severe hyperkalemia and calcium - A call for an additional research
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Aleksandr Gleyzer
       
  • Esophageal bougienage in the emergency department with a substitute Hurst
           dilator
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Jovian Collins, Mark O. Tessaro, Terrance McGovernAbstractImpacted esophageal foreign bodies typically first present to the emergency department, with coins being most common in children and food boluses most common in adults. Controversy exists regarding the best treatment options in these cases. We report two cases, one pediatric and one adult, where the use of a novel substitute Hurst dilator constructed of materials regularly found in all EDs was successfully used to treat impacted esophageal foreign bodies.
       
  • Pentraxin 3 level in acute migraine attack with aura: Patient management
           in the emergency department
    • Abstract: Publication date: January 2020Source: The American Journal of Emergency Medicine, Volume 38, Issue 1Author(s): Mehmet Tahir Gokdemir, Cemal Nas, Gül Sahika GokdemirAbstractObjectivesWe investigated the state of inflammation, PTX3 level and other routine inflammatory markers (high sensitivity C-reactive protein [hsCRP], and white blood cells [WBC]), in patients who presented to the emergency department (ED) with migraine. We also investigated the relationship between the clinical presentation, PTX3 level, and other routine inflammatory markers in the emergency management of these patients.MethodsThe study included 44 patients (group 1) who presented to the ED due to a migraine attack with aura and 44 controls (group 2) with similar demographic characteristics.ResultsThe WBC count was 8.82 ± 2.10 × 109/L in group 1 and 7.85 ± 2.04 × 109/L in group 2. The mean PTX3 level was 11.57 ± 3.99 ng/mL in patients who presented at the ED with a migraine attack, and 4.59 ± 1.28 ng/mL in controls. The differences values of WBC and PTX3 between the two groups were significant (respectively; P = 0.031, P 
       
  • Orthostatic vital signs do not predict 30 day serious outcomes in older
           emergency department patients with syncope: A multicenter observational
           study
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Jennifer L. White, Judd E. Hollander, Anna Marie Chang, Daniel K. Nishijima, Amber L. Lin, Erica Su, Robert E. Weiss, Annick N. Yagapen, Susan E. Malveau, David H. Adler, Aveh Bastani, Christopher W. Baugh, Jeffrey M. Caterino, Carol L. Clark, Deborah B. Diercks, Bret A. Nicks, Manish N. Shah, Kirk A. Stiffler, Alan B. Storrow, Scott T. WilberAbstractBackgroundSyncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope.MethodsWe performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs.ResultsThe study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81–1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62–1.09], p = 0.18).ConclusionsIn a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.
       
  • Risk factors for seizure recurrence in a pediatric observation unit
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Ayse Gultekingil, Ozlem Teksam, Goknur Haliloglu, Dilek YalnizogluAbstractBackgroundMost patients present with seizures to pediatric emergency department (PED) are observed for extended periods for the risk of possible acute recurrence.ObjectiveThe aim of this study is to determine the risk factors of acute recurrence within first 24 h.MethodsPatients who presented to PED with seizure during past 24 h were enrolled. Demographic features, number and duration of seizures, diagnostic studies, physical examination findings, presence and time of seizure recurrence in PED were noted.Results187 patients were eligible for the study. 46% had recurrence of seizures in 24 h, 90,8% of recurrence within the first 6 h. Univariate analysis showed that younger patients, epileptic patients who were on multiple antiepileptic drugs (AEDs), who had multiple seizures during the past 24 h, who had abnormal neurological examination or neuroimaging findings had increased risk of seizure recurrence. Multivariate analysis showed that number of seizures during the past 24 h and previous use of AEDs was significantly associated with increased risk of recurrence.ConclusionRisk factors for acute recurrence should be evaluated for each patient. Patients without risk factors and no seizures during the first 6 h should not be observed for extended periods in PED.
       
  • Intravenous dexketoprofen versus paracetamol in non-traumatic
           musculoskeletal pain in the emergency department: A randomized clinical
           trial
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Ezgi Demirozogul, Atakan Yilmaz, Mert Ozen, Ibrahim Turkcuer, Murat Seyit, Cuneyt ArikanAbstractIntroductionAlthough acute musculoskeletal pain has a wide range of causes from tendinitis, muscle spasm, to bone and joint injuries, it is a frequent occurrence in emergency services. Paracetamol and non-steroidal anti-inflammatory analgesics (NSAID) are common used in the treatment of musculoskeletal pain. This study sets out to compare the effectiveness of intravenous dexketoprofen and paracetamol in musculoskeletal pain relief.MethodsThis prospective, randomized, double blind, controlled study was carried out in a university emergency room. The participating patients were randomized into two groups to receive either 50 mg of dexketoprofen or 1000 mg of paracetamol intravenously by rapid infusion in 150 ml of normal saline. Visual analogue scale (VAS), Numeric Rating Scala (NRS) was employed for pain measurement at baseline, after 15, after 30 and after 60 mins.Results200 patients were included in the study, excluding 7342 of them. The mean age of the patients was calculated as 32,6. Paracetamol and dexketoprofen intervention decreases NRS pain scores over time. When compared to all pain locations, the NRS pain score of the patients was found to be statistically more effective in dexketoprofen than in paracetamol (p = 0.001). Paracetamol and dexketoprofen intervention reduces pain VAS scores over time. When the VAS pain score of the patients was compared to all pain locations, dexketoprofen was found to be statistically more effective than paracetamol (p = 0.001).ConclusionIntravenous dexketoprofen seemed to achieve superior analgesia to intravenous paracetamol when compared with all pain locations in patients with non-traumatic musculoskeletal pain.
       
  • The intensity of pain in the prehospital setting is most strongly
           reflected in the respiratory rate among physiological parameters
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Andersson Jan-Otto, Nasic Salmir, Herlitz Johan, Hjertonsson Erik, Axelsson ChristerAbstractBackgroundIn order to treat pain optimally, the Emergency Medical Service (EMS) clinician needs to be able to make a reasonable estimation of the severity of the pain. It is hypothesised that various physiological parameters will change as a response to pain.AimIn a cohort of patients who were seen by EMS clinicians, to relate the patients' estimated intensity of pain to various physiological parameters.MethodsPatients who called for EMS due to pain in a part of western Sweden were included. The intensity of pain was assessed according to the visual analogue scale (VAS) or the Numerical Rating Scale (NRS). The following were assessed the same time as pain on EMS arrival: heart rate, systolic and diastolic blood pressure, respiratory rate, moist skin and paleness.ResultsIn all, 19,908 patients (≥18 years), were studied (51% women). There were significant associations between intensity of pain and the respiratory rate (r = 0.198; p 
       
  • Prevalence of attention deficit hyperactivity disorder (ADHD) in children
           presenting with foreign body ingestion
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Kasım Turgut, Mehmet Kaan Poyraz, Ebru Sekmen, İrfan Aydın, Abdullah Algın, Erdal YavuzAbstractBackgroundForeign body ingestion is a common condition in children. We aimed to compare the incidence of attention deficit hyperactivity disorder (ADHD) symptoms in children that ingested foreign bodies with healthy children.MethodsThe study group consisted of 3- to 17-year-old pediatric patients admitted to the emergency department after foreign body ingestion, and the control group was formed with children having similar demographic and cultural characteristics that presented to the same department for non-traumatic causes. After initial intervention and stabilization, we administered the Conners' Parent Rating Scales-Revised (CPRS-R) to both groups.ResultsThe study group consisted of 53 patients with a mean age of 7.83 ± 4.36 and the control group comprised 47 children with a mean age of 7.72 ± 3.48 years. There were no statistically significant differences between the study and control groups in terms of age, gender, and parental education levels (p > 0.05 for each). The foreign objects most ingested by children were coins (32.1%), followed by needles (15.1%) and beads (9.4%), and all the patients recovered without complications and were discharged. All the CPRS-R subscale scores were significantly higher in the study group than in the control group (p 
       
  • TOC
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s):
       
  • Sensitivity of a bedside reagent strip for the detection of spontaneous
           bacterial peritonitis in ED patients with ascites
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Brian Chinnock, Robert E. Woolard, Gregory W. Hendey, Scott Crawford, Leann Mainis, Daniel Vo, Radosveta N. Wells, René Ramirez, Deena I. BengiaminAbstractStudy objectiveTo determine the sensitivity of a highly sensitive bedside leukocyte esterase reagent strip (RS) for detection of spontaneous bacterial peritonitis (SBP) in emergency department (ED) ascites patients undergoing paracentesis.MethodsWe conducted a prospective, observational cohort study of ED ascites patients undergoing paracentesis at two academic facilities. Two practitioners, blinded to each other's results, did a bedside RS analysis of the peritoneal fluid in each patient and documented the RS reading at 3-min according to manufacturer-specified colorimetric strip reading as either “negative”, “trace”, “small”, or “large”. The primary outcome measure was sensitivity of the RS strip for SBP (absolute neutrophil count ≥ 250 cells/mm3) at the “trace” threshold (positive equals trace or greater).ResultsThere were 330 cases enrolled, with 635 fluid analyses performed. Of these, 40 fluid samples had SBP (6%). Bedside RS had a sensitivity, specificity, positive predictive value, and negative predictive value of 95% (95% CI 82%–99%), 48% (95% CI 44%–52%), 11% (95% CI 10%–11%), and 99% (95% CI 97%–99%) respectively at the “trace” threshold for the detection of SBP.ConclusionBedside use of the RS in ED ascites patients demonstrated high sensitivity for SBP. Given the wide confidence intervals, we cannot currently recommend it as a stand-alone test. We recommend further study with a larger number of SBP patients, potentially combining a negative RS result with low clinical suspicion to effectively rule out SBP without formal laboratory analysis.
       
  • Validity of the Japan Acuity and Triage Scale in elderly patients: A
           cohort study
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Akira Kuriyama, Toshie Kaihara, Tetsunori IkegamiAbstractBackgroundIn developed nations, the age of patients in emergency departments (ED) continues to increase. Many emergency triage systems, such as the Canadian Triage and Acuity Scale (CTAS), triage patients as a homogenous group, regardless of age. However, older adults have multiple comorbidities and a higher risk of undertriage. The Japan Acuity and Triage Scale (JTAS) was developed based on the CTAS and has been validated for overall adults. We assessed the validity of the JTAS for use in elderly ED patients.MethodsThis was a secondary analysis of a cohort study that previously validated the JTAS in self-presenting adults of all ages in the ED of a Japanese tertiary-care hospital. We included non-transferred patients who were ≥65 years old and triaged between June 2013 and May 2014. Our primary outcome measures were overall admission and ED length of stay. Our secondary outcomes included admission to the intensive care units (ICUs) and in-hospital mortality. We examined the association between the triage level and patient outcomes with multivariable logistic regression analysis (overall and ICU admission and in-hospital mortality) and the Kruskal-Wallis rank-sum test (ED length of stay).ResultsWe included a total of 11,087 elderly patients in our study. Higher odds ratios for overall and ICU admission and in-hospital mortality corresponded to higher acuity levels. ED length of stay was significantly longer in patients with a higher JTAS level (p 
       
  • Prehospital quick sequential organ failure assessment score to predict
           in-hospital mortality among patients with trauma
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Kyohei Miyamoto, Naoaki Shibata, Atsuhiro Ogawa, Tsuyoshi Nakashima, Seiya KatoAbstractObjectiveThe quick sequential organ failure assessment (qSOFA) score is calculated from three variables measured at the scene of trauma—systolic blood pressure, respiratory rate and consciousness. This study aimed to evaluate the discriminative ability of the prehospital qSOFA score for in-hospital mortality in patients with trauma.MethodsThis retrospective multicenter study used data from 42,722 patients with trauma included in a Japanese nationwide trauma registry. All included patients were aged ≥18 years old and transferred to hospitals from the scenes of injury. The primary outcome was in-hospital mortality.ResultsThe included patients had a mean age of 59.4 ± 21.5 years and a male predominance (63%). In-hospital mortality occurred in 2612 patients (6%), while 2-day mortality occurred in 1189 of 42,339 patients (3%). When patients were stratified by qSOFA scores, in-hospital mortality rates of 0.9% (105/11783), 5% (941/17839), 12% (1280/11132) and 15% (286/1968) were associated with qSOFA scores of 0, 1, 2 and 3, respectively (P 
       
  • New classifications for Life-threatening foreign body airway obstruction
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Yutaka Igarashi, Tatsuya Norii, Kim Sung-Ho, Shimpei Nagata, Takashi Tagami, Jon Femling, Yasuaki Mizushima, Hiroyuki YokotaAbstractIntroductionForeign body airway obstruction (FBAO) is a common medical emergency; however, few studies of life-threatening FBAO have been reported and no standard classification system is available.MethodsWe retrospectively evaluated patients who presented to the emergency departments of two hospitals and were diagnosed with FBAO. The primary outcome was cerebral performance category (CPC) score at discharge. To establish a new classification system for FBAO, FBAO was classified into three types based on the anatomical and physiological characteristics of the obstructed airway.ResultsA total of 137 patients were enrolled. Median age was 79.0 years. The most common cause of FBAO was meat, followed by bread, rice cake, and rice. Of all patients, 65.7% suffered cardiac arrest and 51.1% died. In contrast, 28.5% had favorable neurological outcomes, defined as CPC 1 and 2. Upper airway obstruction (type 1) was the most common (type 1, 78.1%), while trachea and/or bilateral main bronchus obstruction (type 2, 12.4%) showed significantly higher mortality than type 1 obstruction (82.4% vs 47.7%, P = 0.0078). Patients with unilateral bronchus and/or distal bronchus obstruction (type 3, 9.5%) were significantly more likely to consume a dysphagia diet than type 1 patients (23.1% vs 0%, P 
       
  • Accuracy of ultrasound for endotracheal intubation between different
           transducer types
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Michael Gottlieb, Dallas Holladay, Katharine Burns, Stephen R. Gore, Collin Wulff, Shital Shah, John BailitzAbstractIntroductionUltrasound has been increasingly utilized for the identification of endotracheal tube (ETT) location after an intubation attempt, particularly among patients in cardiac arrest. However, prior studies have varied with respect to the choice of transducer and no studies have directly compared the accuracy between transducer types. Our study is the first to directly compare the accuracy of ETT confirmation between the linear and curvilinear transducer.MethodsThis study was performed in a cadaver lab using three different cadavers chosen to represent varying neck circumferences. Cadavers were randomized to tracheal or esophageal intubation. Blinded sonographers assessed the location of the ETT using either a linear or curvilinear transducer in an alternating sequence. Accuracy of sonographer identification, time to identification, and operator confidence were assessed.ResultsFour hundred and five assessments were performed with 198 (48.9%) tracheal and 207 (51.1%) esophageal intubations. The linear transducer was 98% (95% CI 95.1% to 99.2%) accurate. The curvilinear transducer was 95% (95% CI 91.1% to 97.3%) accurate. The mean time to identification was significantly lower with the linear transducer [7.46 s (95% CI 6.23 to 8.7 s)] as compared with the curvilinear transducer [11.63 s (95% CI 9.05 to 14.2 s)]. The mean operator confidence was significantly higher with the linear transducer [4.84/5.0 (95% CI 4.76 to 4.91)] than with the curvilinear transducer [4.44/5.0 (95% CI 4.3 to 4.57)]. All operators preferred the linear transducer over the curvilinear transducer.ConclusionThe diagnostic accuracy of ultrasound for ETT confirmation did not significantly differ between ultrasound transducer types, but the curvilinear transducer was associated with a longer time to confirmation and lower operator confidence. Further studies are needed to determine if the accuracy would change with more novice providers or in specific patient populations.
       
  • Designing efficient emergency departments: Discrete event simulation of
           internal-waiting areas and split flow sorting
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Benjamin Easter, Negin Houshiarian, Debajyoti Pati, Jennifer L. WilerAbstractObjectiveEvaluate nine different models, the interaction of three flow models (ESI, intake attending physician, and no split flow) and three physical design typologies (zero, one, and two internal-waiting areas), on Emergency Department (ED) flow and patient-centered metrics.MethodsDiscrete Event Simulation (DES) was used to systematically manipulate flow and physical design. Three base models were developed and validated using ED and patient specific data. Subsequently, systematic manipulations of flow and internal-waiting areas were performed on other models. Five outcomes of interest were tracked – length of stay (LOS), bed utilization rate, door to provider time, left without being seen rate, and number of movements per patient. Models were compared for statistical significance and effect size using ANOVA, and linear and non-linear regression.ResultsThe shortest LOS (mean 175.2 min) and highest bed utilization rate (5.02 patients/bed/day) were obtained with flow split by an intake attending physician with two internal-waiting areas. These represented improvements of 54 min and 1.48 patients/bed/day over the control model. Two-way ANOVA demonstrated that both physical design and flow type were statistically significant predictors of all outcomes of interest (p 
       
  • Incidence and risk factors for hyperlactatemia in ED patients with acute
           metformin overdose
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Emily S. Taub, Robert S. Hoffman, Alex F. ManiniAbstractIntroductionThe goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose.MethodsThis was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH
       
  • Effect of two tourniquet techniques on peripheral intravenous cannulation
           success: A randomized controlled trial
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Theresa Tran, Sarah B. Lund, Micah D. Nichols, Tobias KummerAbstractObjectivesPeripheral intravenous (IV) cannulation is the most common procedure performed in the emergency department (ED). Elastic tourniquets (ETs) and blood pressure cuffs (BPCs) are frequently used for venodilation. Although BPCs lead to increased venodilation and decreased compressibility, it is unclear whether this translates into a meaningful patient-centered outcome. This study aimed to determine whether one method is superior for success on the first attempt.MethodsThis was a prospective, single-blinded, randomized controlled trial in the ED of a tertiary care center. A convenience sample of adult patients was randomly assigned to an ET or BPC with a cover concealing the type of tourniquet. The primary outcome was success rate on the first attempt. Secondary outcomes were number of attempts, number of providers, and rate of rescue techniques.ResultsOf the 121 patients enrolled, 119 qualified for analysis. In the ET group, 42 of 59 patients (71%) had successful IV cannulation on first attempt compared with 43 of 60 (72%) in the BPC group (P = .95). The number of attempts (P = .87), number of nurses (P = .67), and use of rescue techniques (P = .32) did not differ significantly. A history of difficult IV access and site other than the antecubital vein were associated with decreased success.ConclusionsETs and BPCs performed similarly in providing venodilation for successful peripheral IV cannulation. History of difficult IV access and IV site are important factors in determining the likelihood of success.
       
  • Usefulness of RBC distribution width and C-reactive protein to predict
           mortality in pediatric non-cardiac critical illness
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Gang Li, Peng Jia, Jian Zhao, Xingdan Wu, Yan Duan, Dong Liu, Ting Wang, Bin LiuAbstractIntroductionWe aimed to assess the performance of red blood cell distribution width (RDW), C-reactive protein (CRP) or the combination of both to predict clinical outcomes in pediatric non-cardiovascular critical illness.Materials and methodsWe analyzed 404 pediatric non-cardiovascular critically ill patients admitted to pediatric intensive care unit (PICU). Potential predictors were identified using multivariable logistic regression. We also calculated the power of RDW and CRP additive to pediatric critical illness score (PCIS) to predict mortality with calculation of C-index value, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices.ResultsRDW and CRP independently predicted PICU mortality. The C-index value of PCIS with respect to prediction of PICU mortality was greater than that of RDW and CRP. The combination of RDW or CRP or both with PCIS did significantly increase C-index value for predicting mortality (all p 
       
  • WAMAMI: emergency physicians can accurately identify wall motion
           abnormalities in acute myocardial infarction
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Peter E. Croft, Tania D. Strout, Randy M. Kring, Laura Director, Samip C. Vasaiwala, David C. MackenzieAbstractObjectiveThe ability to identify wall motion abnormalities may be useful for emergency clinicians, but is not typically evaluated in point-of-care echocardiograms. We sought to determine if emergency physicians with basic training in emergency echocardiography could identify regional wall motion abnormalities (RWMA) in patients admitted with ST-elevation myocardial infarction (STEMI).MethodsWe prospectively enrolled patients with admitted with STEMI. Resident physicians with basic training in emergency ultrasound, blinded to other patient data, performed a point-of-care echocardiogram to evaluate for RWMA. If present, they also recorded the suspected territory of the RWMA. We calculated test performance characteristics and compared the agreement between point-of-care and comprehensive echocardiogram for RWMA and territory.Results75 patients with STEMI were enrolled, and 62% had a RMWA. RWMA were identified with excellent test performance characteristics (sensitivity 88% (95% CI 75–96); specificity 92% (95% CI 75–99)). There was substantial agreement between the point-of-care echocardiogram and reference standard (K = 0.79; 95% CI: 0.64–0.94).ConclusionsEmergency physicians with core training in point-of-care echocardiography can accurately identify RMWA.
       
  • An analysis of randomized controlled trials underpinning ST-elevation
           myocardial infarction management guidelines
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Chase Meyer, Aaron Bowers, Dev Jaiswal, Jake Checketts, Michael Engheta, Caleb Severns, Sharolyn Cook, Corbin Walters, Matt VassarAbstractBackgroundThe fragility index (FI) is calculated by iteratively changing one outcome “event” to a “non-event” within a trial until the associated p-value exceeds 0.05.PurposeTo investigate the FI and fragility quotient (FQ) of trial endpoints referenced in the ACCF/AHA/SCAI guidelines in the management of ST-elevation myocardial infarctions. Secondarily, we assess the post-hoc power and risk of bias for these specific outcomes and whether differences exist between adequately and inadequately powered studies on fragility measures.Basic proceduresAll citations referenced in the guideline were screened for inclusion criteria. The FI and FQ for all included trials were then calculated. The Cochrane ‘risk of bias’ Tool 2.0 was used to evaluate the likelihood and sources of bias in the included trials.Main findingsForty-two randomized controlled trials were included for assessment. The median FI was 10 with a FQ of 0.0055. Seven trials were at a high risk of bias, all due to bias in the randomization process. Fifteen trials were found to be underpowered. Adequately powered studies had higher FIs and FQs compared to underpowered studies.Principal conclusionsOur findings support the use of FI and FQ analyses with power analyses in future methodology of randomized control trials. With understanding and reporting of FI and FQ, evidence of studies can be readily available and quickly eliminate some readers' concern for possible study limitations.
       
  • Sepsis is frequent in initially non-critical hypotensive emergency
           department patients and is associated with increased mortality
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Sean Coeckelenbergh, Marc Van Nuffelen, Christian MélotAbstractObjectiveHypotension, defined as a mean arterial pressure of maximum 70 mmHg, is associated with significant morbidity and mortality. The objective of this study was to determine in initially non-critical hypotensive adult patients the proportion of sepsis and if septic patients had different outcome and clinical factors than non-septic patients.MethodsThis retrospective observational study was conducted over a year on adult hypotensive emergency department patients initially considered by triage as non-critical. Patients were separated into three groups: hypotensive septic patients (HSP), hypotensive non-septic infected patients (HNSIP), and other hypotensive patients (OHP). Clinical scores, signs, length of stay (LOS), and mortality were compared using analysis of variance for continuous variables and chi-square analysis for categorical variables.ResultsThere were 136 (35.5%) septic patients, 37 (9.7%) with non-septic infection, and 210 (54.8%) with another cause of hypotension. Overall in-hospital mortality was 12.0% and total mortality was greater in HSP than in HNSIP (20.6% vs. 5.4%, p = 0.031) or OHP (20.6 vs. 7.6%, p 
       
  • Suicide and the creation of evidence-based guidelines: the ACEP
           perspective
    • Abstract: Publication date: December 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 12Author(s): Paul D. Kivela
       
 
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