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Publisher: Elsevier   (Total: 3182 journals)

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Showing 1 - 200 of 3182 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: 103, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 42, 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: 440, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 29, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 11, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 5, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 318, 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 Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
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  
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: 11, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 23)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 187, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 12, 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: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 34, 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: 10, 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: 20, 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: 15)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 13)
Advances in Digestive Medicine     Open Access   (Followers: 12)
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: 44, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 29, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 8)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 52, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 66, 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: 11, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 7, 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: 15, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 8, 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: 25)
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: 5, 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: 9, 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: 10)
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: 68)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 2, 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: 6)
Advances in Space Research     Full-text available via subscription   (Followers: 425, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
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: 38, 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: 54, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 386, 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: 481, 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: 31, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 44, 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: 53, 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: 65, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 47, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 12)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 37, 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: 36, 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: 263, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 66, 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: 28, 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: 5, 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: 210, 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: 227, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 7, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)

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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: 47  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0735-6757
Published by Elsevier Homepage  [3182 journals]
  • Comparison of high-flow nasal cannula oxygen therapy and conventional
           
    • Abstract: Publication date: Available online 6 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Young-Min Kim, Hyun-Jo Shin, Dong-won Choi, Ji-Min Kim, Suk-Woo Lee, Seong-Hae Jeong, Hoon Kim BackgroundHigh-flow nasal cannula oxygen (HFNC) creates a positive pressure effect through high-flow rates compared to conventional oxygen therapy. The purpose of this human pilot study is to compare the effects of HFNC and conventional oxygen therapy on the rate of carbon monoxide (CO) clearance from the blood in patients with mild to moderate CO poisoning.MethodsCO-poisoned Patients randomly received 100% oxygen from a rebreathing reserve mask (NBO2, flow of 15 L/min) or HFNC (flow of 60 L/min). The fraction of COHb value (fCOHb) was measured in 30-min intervals until it fell to under 10%. We determined the Half-life time of fCOHb (fCOHb t1/2).ResultsA total of 22 patients had fCOHb levels ≥ 10% at the time of ED arrival, with 9 of them having fCOHb level ranging between 25% and 50%. There was no significant difference in the fCOHbt1/2 between the HFNC group and NBO2 group. However, the mean fCOHbt1/2 in the HFNC group (48.5 ± 12.4 min) has a smaller standard deviation than that in the NBO2 group (99.3 ± 93.38 min). There were significant between-group differences in the mean COHbt1/2 among the patients with fCOHb levels less than 25% (HFNC 43.6 ± 10.6 vs. NBO2 134.2 ± 111.3).ConclusionsIn this pilot randomized controlled trial study, HFNC therapy did not reduce fCOHbt1/2 compared to NBO2 therapy but could be beneficial in maintaining a constant fCOHbt1/2 as well as in reducing fCOHbt1/2 in mild CO poisoning patients compared to conventional NBO2 therapy. However, further studies with a larger number of patients are needed to establish HFNC therapy as an alternative therapy for CO poisoning patients.
       
  • Reply to “Urolithiasis diagnosis with CHOKAI rule; are we there
           yet'”
    • Abstract: Publication date: Available online 4 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Hiroki Fukuhara, Masaki Nakane, Norihiko Tsuchiya
       
  • How much change in pain score does really matter to patients'
    • Abstract: Publication date: Available online 4 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Maryam Bahreini, Arash Safaie, Hadi Mirfazaelian, Mohammad Jalili ObjectiveThe goal of this study was to determine the minimal change in pain score recognized by patients as meaningful known as minimal clinically important difference (MCID).MethodsPain was recorded upon admission, 30 and 60 minutes later and patients were asked to describe the extent of pain change on a 5-point Likert scale ranging from “much better” to “much worse”. Patients reported their pain by two common pain scales comprising numeric rating scale (NRS) and visual analog scale (VAS). We used receiver operating characteristic curve to assess the accuracy of pain scales. We then calculated the mean change in pain scores among patients who reported their pain change as “a little better” or “a little worse” and also analyzed regression to evaluate the MCID.ResultsA total of 150 patients and 253 pain changes were recruited. The MCID ± SD (95% CI) was 1.65 ± 1.58 (1.32-1.97) for NRS and 16.55 ± 17.53 (12.96 - 20.15) for VAS. The area under the curve by NRS and VAS were 0.86 and 0.89. For linear regression, the line slope and the y-intercept were 17.56 and 1.88, for VAS; these values were 1.73 and 0.31 for NRS, respectively.ConclusionsRecognizing the extent of change in pain score that really matters to patients is crucial for the evaluation of treatment effect. Patients perceived a change of 1.65 points on NRS and 16.55 on VAS in their pain severity as meaningful. This value was not different whether the pain was perceived alleviated or aggravated.
       
  • Rhomboid Intercostal block for multiple rib fractures: should we add a
           continuous infusion'
    • Abstract: Publication date: Available online 1 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Emanuele Piraccini, Thierry Claude Bagaphou, Roberto Righetti
       
  • On first-pass, twitter response is inferior to expectations
    • Abstract: Publication date: Available online 1 November 2019Source: The American Journal of Emergency MedicineAuthor(s): K. Ogle, C. Roche, A. Pourmand
       
  • (MS21362) A technical dilemma: Single shot or continuous injection for
           novel plane blocks'
    • Abstract: Publication date: Available online 1 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Ali Ahiskalioglu, Ahmet Murat Yayik, Muhammed Enes Aydin
       
  • Acute perforated appendicitis after blunt abdominal trauma: A report from
           a 7-year-old boy and literature review
    • Abstract: Publication date: Available online 1 November 2019Source: The American Journal of Emergency MedicineAuthor(s): Zlatan Zvizdic, Irmina Pasic-Sefic, Semir Vranic Individually, trauma and appendicitis are some of the most common conditions in clinical practice, particularly in emergency medicine. In rare cases, trauma and appendicitis may co-exist, imposing a dilemma of whether these are only coincidence or appendicitis develops because of trauma. We report here a case of acute perforated appendicitis after a blunt abdominal trauma caused by a horse hoof kick to the abdomen in a 7-year-old boy. We also discussed the potential pathophysiologic mechanisms behind and reviewed the literature on this rare condition.
       
  • Can Emoji’s Assess Patients’ Mood and Emotion in the Emergency
           Department' An Emoji Based Study
    • Abstract: Publication date: Available online 31 October 2019Source: The American Journal of Emergency MedicineAuthor(s): A. Pourmand, T. Quan, SB. Amini, N. Sikka
       
  • Emergent complication of assisted reproductive technology: clinical
           analysis of 17 pregnant women with adnexal torsion
    • Abstract: Publication date: Available online 24 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Yu Sun, Guofang Feng, Yanling Fu, Jiali You, Miao Li, Yimin Zhu BackgroundThe purpose of this study was to evaluate the clinical symptoms, surgical management, and outcomes of pregnanct women with adnexal torsion due to assisted reproductive technology.MethodsIt was a retrospective study that include 17 pregnant women with adnexal torsion, in which the maternal age, type of fertilization, gestational age, clinical symptoms, ultrasonic findings, side affected by the disease, surgical method, and pregnancy outcomes were evaluated. Results:A total of 17 patients with adnexal torsion were included in this study, of which 8 patients conceived by in vitro fertilization-embryo transfer(IVF-ET),1 by artificial insemination (AIH), and the other 8 conceived naturally after ovulation induction. About 14 were reported to have occurred in the first trimester of pregnancy, 1 case in the second trimester, and the other 2 in the third trimester. Clinical symptoms were abdominal pain with or without nausea and vomiting. 14 cases occurred in the right adnexa and the other 3 in the left. 5 of the patients underwent laparoscopy, and the other 12 underwent laparotomy. 8 cases were of full- term delivery, 6 twins gave birth prematurely, and 3 patients had inevitable abortion.ConclusionsAdnexal torsion is an acute onset of lower abdominal pain in women, which seldom occurs during pregnancy. However, because of the wide application of assisted reproductive technology(ART), its incidence has increased. Early diagnosis and treatment can lead to better results.
       
  • Inhaled Budesonide for the Prevention of Acute Mountain Sickness: A
           Meta-Analysis of Randomized Controlled Trials
    • Abstract: Publication date: Available online 23 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Zhu Xiong, Liu Yunrui, Li Na, He Qing BackgroundAltitude induces acute mountain sickness (AMS), which can affect the health or limit the activities of 15% to 80% of climbers and workers. Budesonide has been applied to prevent AMS. However, its prophylactic efficacy is controversial. Our purpose was to conduct a meta-analysis to assess whether budesonide qualifies as a prophylaxis for AMS.MethodsA literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library in February 2019. Only randomized controlled trials (RCTs) were selected. The main outcome, AMS, was estimated with the relative risk (RR), weighted mean difference (WMD), and 95% confidence intervals (95% CI). The statistical analysis was performed using Rev. Man 5.3.ResultsFive groups in six articles met the eligibility criteria with 304 participants, including two articles with the same participants but different measurements. Inhaled budesonide showed a potential trend towards preventing AMS, but it was not statistically significant (RR=0.68, 95% CI: 0.41 to 1.13, p = 0.14). The subgroup analysis based on dosage (200 µg) did not have significant results. A similar trend was observed for severe AMS and in subgroups stratified by the Lake Louise Score (LLC). However, there was a significant improvement in heart rate (HR) (WMD=-5.41, 95% CI: -8.26 to -2.55, p = 0.0002) and pulse oxygen saturation (SPO2) (WMD=2.36, 95% CI: 1.62 to 3.1, p < 0.00001) in the group with inhaled budesonide. Additionally, no side effects were reported in any included study.ConclusionThe current meta-analysis indicates that inhaled budesonide does not protect against AMS or severe AMS. However, it is successful at reducing HR and increasing SPO2 without any side effects.
       
  • Atomized intranasal vs intravenous fentanyl in severe renal colic pain
           management: A randomized single-blinded clinical trial
    • Abstract: Publication date: Available online 23 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Narjes Nazemian, Mehdi Torabi, Moghaddameh Mirzaee
       
  • Barriers to Breastfeeding for Emergency Medicine Physicians in the
           Emergency Department
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): T. Whiteside, S.E. Frasure, K. Ogle, A. Pourmand
       
  • Pseudo-Pulseless Electrical Activity in the Emergency Department, An
           Evidence based Approach
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): J. Rabjohns, T. Quan, K. Boniface, A. Pourmand IntroductionA great deal of the literature has focused specifically on true pulseless electrical activity (PEA), whereas there is a dearth of research regarding pseudo-PEA. This narrative review evaluates the diagnosis and management of patients in pseudo-PEA and discusses the impact on emerging patient outcomes.DiscussionPseudo-PEA can be defined as evidence of cardiac activity without a detectable pulse. Distinguishing pseudo-PEA from true PEA is important for emergency physicians as the prognosis and management of these patients differ. POCUS is the tool most commonly used to diagnose pseudo-PEA and there are varying treatment strategies to manage these patients. Identifying patients in pseudo-PEA can help guide resuscitation decisions, and ultimately impact emergency response systems, patients, and families.ConclusionsThe incidence of pseudo-PEA is increasing. Effective care of these patients begins with early diagnosis of this condition and immediate treatment to warrant the greatest chance of survival. There is a need for further prospective studies surrounding pseudo-PEA as evidenced by the lack of research in the current literature.
       
  • The efficacy of tranexamic acid for traumatic brain injury: a
           meta-analysis of randomized controlled studies
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Hongshen Chen, Muhu Chen BackgroundTranexamic acid shows some treatment efficacy for traumatic brain injury. This systematic review and meta-analysis is conducted to investigate the efficacy of tranexamic acid for traumatic brain injury.MethodsThe databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched for collecting the randomized controlled trials (RCTs) regarding the efficacy of tranexamic acid for traumatic brain injury.ResultsThis meta-analysis has included six RCTs. Compared with placebo group in patients with traumatic brain injury, tranexamic acid results in remarkably reduced mortality (risk ratio (RR)=0.91; 95% confidence interval (CI)=0.85 to 0.97; P=0.004) and growth of hemorrhagic mass (RR=0.78; 95% CI=0.61 to 0.99; P=0.04), but has no important impact on neurosurgery (RR=0.99; 95% CI=0.85 to 1.15; P=0.92), extracranial surgery (RR=1.00; 95% CI=0.97 to 1.04; P=0.99), unfavorable outcome (Glasgow Outcome Scale, GOS) (RR=0.72; 95% CI=0.47 to 1.11; P=0.14), pulmonary embolism (RR=1.86; 95% CI=0.42 to 8.29; P=0.42), and deep venous thrombosis (RR=0.97; 95% CI=0.64 to 1.47; P=0.88).ConclusionsTranexamic acid is associated with substantially reduced mortality and growth of hemorrhagic mass in patients with traumatic brain injury, but the need of neurosurgery and extracranial surgery, as well as the risk of unfavorable outcome (GOS) are similar between tranexamic acid and placebo.
       
  • Correspondence MS 21215 – Role of Repeat Head CT in patients with mild
           traumatic intracranial injury
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Pierre Borczuk
       
  • Serum Pentraxin-3 levels in acute cholecystitis: Helpful in emergency
           decision-making'
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Ufuk İlgen
       
  • Electronic Medical Record-Based Interventions to Encourage Opioid
           Prescribing Best Practices in the Emergency Department
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Courtney M. Smalley, Marc A. Willner, McKinsey R. Muir, Steven W. Meldon, Brad L. Borden, Fernando J. Delgado, Baruch S. Fertel ObjectiveOverdose from opioids has reached epidemic proportions. Large healthcare systems can utilize existing technology to encourage responsible opioid prescribing practices.Our study measured the effects of using the electronic medical record (EMR) with direct clinician feedbackto standardize opioidprescribing practices within a large healthcare system.MethodsThisretrospective multicenter studycompared a 12-month pre- and post-intervention in 14 emergency departments after four interventions utilizing the EMR were implemented: 1) deleting clinician preference lists, 2) defaulting dose, frequency, and quantity, 3) standardizing formulary to encourage best practices, and 4) creating dashboards for clinician review with current opioid prescribing practices. Outlyingclinicians received feedback through email and direct counseling.Total number of opioid prescriptions per100 discharges pre- and post-intervention were recorded as primary outcome. Secondary outcomes included number of prescriptions per 100 discharges/clinician exceeding 3-day supply (defined as 12 tablets), number exceeding 30 morphine equivalent daily dose (MEDD)/day, and number of non-formulary prescriptions.ResultsThere were>700,000 discharges during pre- andpost-intervention periods.Percentage oftotal number opioid prescriptions per 100 discharges decreased from 14.4% to 7.4%, a 7.0% absolute reduction, (95% CI,6.9%-7.2%). There was a 5.9% to 0.7% reduction in prescriptions exceeding 3-days, (95% CI, 5.1%-5.3%), a 4.3% to 0.3% reduction in prescriptions exceeding 30 MEDD, (95% CI, 3.9%-4.0%), and a 0.3% to 0.1% reduction in non-formulary prescriptions, (95% CI, 0.2%-0.3%).ConclusionsA multi modal approach using EMR interventions which provide real time data and direct feedback to clinicians can facilitate appropriate opioid prescribing.
       
  • High-speed handling of a haemorrhage control system by first-responders
           and physicians
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Paul-Georges Reuter, Sarah Tepper, Hayatte Akodad, Antoine Lesecq, Camille Freedman, Jean-Marc Agostinucci, Tomislav Petrovic, Frédéric Adnet, Frédéric Lapostolle
       
  • Fulminant diabetes due to immune checkpoint inhibitors in the emergency
           department
    • Abstract: Publication date: Available online 14 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Olivier Peyrony, Sami Ellouze, Jean-Paul Fontaine, Inna Mohamadou, Lara Zafrani Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.
       
  • ECPR in acute aortic dissection – Really a no-go'
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): L. Christian Napp, Andreas Martens
       
  • Dysrhythmias and heart failure complicating acute myocardial infarction:
           An emergency medicine review
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): William T. Davis, Tim Montrief, Alex Koyfman, Brit Long IntroductionPatients with acute myocardial infarction (AMI) may suffer several complications after the acute event, including dysrhythmias and heart failure (HF). These complications place patients at risk for morbidity and mortality.ObjectiveThis narrative review evaluates literature and guideline recommendations relevant to the acute emergency department (ED) management of AMI complicated by dysrhythmia or HF, with a focus on evidence-based considerations for ED interventions.DiscussionLimited evidence exists for ED management of dysrhythmias in AMI due to relatively low prevalence and frequent exclusion of patients with active cardiac ischemia from clinical studies. Management decisions for bradycardia in the setting of AMI are determined by location of infarction, timing of the dysrhythmia, rhythm assessment, and hemodynamic status of the patient. Atrial fibrillation is common in the setting of AMI, and caution is warranted in acute rate control for rapid ventricular rate given the possibility of compensation for decreased ventricular function. Regular wide complex tachycardia in the setting of AMI should be managed as ventricular tachycardia with electrocardioversion in the majority of cases. Management directed towards HF from left ventricular dysfunction in AMI consists of noninvasive positive pressure ventilation, nitroglycerin therapy, and early cardiac catheterization. Norepinephrine is the first line vasopressor for patients with cardiogenic shock and hypoperfusion on clinical examination. Early involvement of a multi-disciplinary team is recommended when caring for patients in cardiogenic shock.ConclusionsThis review discusses considerations of ED management of dysrhythmias and HF associated with AMI.
       
  • Point-of-care ultrasound for the evaluation of non-traumatic visual
           disturbances in the emergency department: The VIGMO protocol
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): Kavita Gandhi, William Shyy, Starr Knight, Nathan Teismann ObjectivesTo establish a standardized approach for the rapid and accurate identification of non-traumatic, ophthalmologic pathology in patients with eye complaints in the emergency department.MethodsIn this detailed protocol we offer an easy, reproducible method for the use of ocular point-of-care ultrasound (POCUS) in helping practitioners identify and distinguish between common eye pathology encountered in the emergency setting: retinal detachment, vitreous detachment, vitreous hemorrhage, optic nerve pathology, and syneresis.ConclusionsThis protocol can help identify patients that may need urgent ophthalmology consultation those that can follow-up on an outpatient, and those that may need additional emergent testing.
       
  • Cardioversion of pre-excited atrial fibrillation leading to ventricular
           fibrillation- case report and review of literature
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): Asaf Danon, Arie Militianu, Jorge E. Schliamser Pre-excited, fast conducting atrial fibrillation (AF) is a serious life-threatening arrhythmia that requires urgent pharmacological or electrical cardioversion. When anti-arrhythmic medications fail to restore sinus rhythm, biphasic, direct current (DC) cardioversion is required. Appropriate synchronization of the DC shock with the QRS is crucial, however not easily achieved. Since the QRS-T complexes in pre-excited AF are severely distorted, the diagnosis of inaccurate synchronization may be overlooked. Here, we report a unique case where during electrical cardioversion of pre-excited AF with inappropriate synchronization on the T wave inadvertently resulted in ventricular fibrillation (VF), and review the literature.
       
  • Reliability of smartphone measurements of vital parameters: A prospective
           study using a reference method
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): İsmail Tayfur, Mustafa Ahmet Afacan ObjectiveIn this study, we aimed to evaluate the accuracy of HR and SaO2 data obtained using a smartphone compared with the measurements of a vital signs monitor (VSM) and an arterial blood gas (ABG) device, respectively.Material and methodsIn this single-center prospective study, the HR and SaO2 measurements were performed using the built-in sensor and light source of a Samsung Galaxy S8 smartphone and compared to the results of VSM and ABG device. The Bland-Altman analysis was used to evaluate and visualize the agreement between the methods.ResultsThe data of 101 patients were analyzed. There was a high correlation between HR measured by smartphone and HR measured by VSM [P 
       
  • C-reactive protein or erythrocyte sedimentation rate results reliably
           exclude invasive bacterial infections
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): Niloufar Paydar-Darian, Amir A. Kimia, Michael C. Monuteaux, Kenneth A. Michelson, Assaf Landschaft, Alexandra B. Maulden, Rachel L. Chenard, Lise E. Nigrovic BackgroundClinicians utilize inflammatory markers, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), to identify febrile children who may have an occult serious illness or infection.ObjectivesOur objective was to determine the relationship between invasive bacterial infections (IBIs) and CRP and ESR in febrile children.MethodsWe performed a retrospective cross-sectional study of 1460 febrile children
       
  • Sepsis alerts in EMS and the results of pre-hospital ETCO2
    • Abstract: Publication date: August 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 8Author(s): Steven J. Weiss, Angel Guerrero, Christian Root-Bowman, Amy Ernst, Kurt Krumperman, Jon Femling, Phil Froman BackgroundField sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection.MethodsIn 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a “sepsis alert” on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as>4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2.Results351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was −0.45. A ROC curve analysis of ETCO2 vs. lactate>4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population.ConclusionWhile ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.
       
  • Recognition, Prevention, and Treatment of Delirium in Emergency
           Department: An Evidence-Based Narrative Review
    • Abstract: Publication date: Available online 8 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Sangil Lee, Michael Gottlieb, Paul Mulhausen, Jason Wilbur, Heather Reisinger, Jin H. Han, Ryan Carnahan BackgroundDelirium is an acute disorder of attention and cognition that is common, serious, costly, under-recognized, and potentially fatal. Delirium is particularly problematic in the emergency department (ED) care of medically complex older adults, who are being seen in greater numbers.ObjectiveThis evidence-based narrative review focuses on the key components of delirium screening, prevention, and treatment.DiscussionThe recognition of delirium requires a systematic approach rather than a clinical gestalt alone. Several delirium assessment tools with high sensitivity and specificity, such as delirium triage screen and brief Confusion Assessment Method, can be used in the ED. The prevention of delirium requires environmental modification and unique geriatric care strategies tailored to the ED. The key approaches to treatment include the removal of the precipitating etiology, re-orientation, hydration, and early mobilization. Treatment of delirium requires a multifaceted and comprehensive care plan, as there is limited evidence for significant benefit with pharmacological agents.ConclusionOlder ED patients are at high risk for current or subsequent development of delirium, and a focused screening, prevention, and intervention for those who are at risk for delirium and its associated complications are the important next steps.
       
  • Accuracy of pre-hospital HEART score risk classification using point of
           care versus high sensitive troponin in suspected NSTE-ACS
    • Abstract: Publication date: Available online 8 October 2019Source: The American Journal of Emergency MedicineAuthor(s): Dominique N. van Dongen, Marion J. Fokkert, Rudolf T. Tolsma, Aize van der Sluis, Robbert J. Slingerland, Erik A. Badings, Arnoud W.J. van 't Hof, Jan Paul Ottervanger IntroductionPre-hospital risk classification by the HEART score is performed with point of care troponin assessment. However, point of care troponin is less sensitive than high sensitive troponin measurement which is used in the hospital setting. In this study we compared pre-hospital HEART-score risk classification using point of care troponin versus high sensitive troponin.MethodsIn 689 consecutive patients with suspected NSTE-ACS, point of care troponin and laboratory high-sensitive troponin were measured in pre-hospital derived blood. For every patient the HEART score with both point of care troponin (HEART-POC) and high sensitive troponin (HEART-hsTnT) was determined. Endpoint was MACE within 45 days.ResultsMean age was 64 (SD±14), 163 (24%) patients were considered low-risk by HEART-hsTnT and 170 (25%) by HEART-POC. MACE was observed in 17%. Although high sensitive versus POC troponin scoring was different in 130 (19%) of patients, in 678 (98%) patients risk classification in low versus intermediate-high risk was similar. The predictive values of HEART-POC versus HEART-HsTnT was similar (AUC 0.75 versus 0.76, p = 0.241).ConclusionAlthough high sensitive versus POC troponin scoring was dissimilar in one fifth of patients, this resulted in different patient risk classification in only 2 percent of patients. Therefore POC troponin measurement suffices for pre-hospital risk stratification of suspected NSTE-ACS.
       
  • Finding the niche: An interprofessional approach to defining oritavancin
           use criteria in the emergency department
    • Abstract: Publication date: Available online 12 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Jared Baxa, Erin McCreary, Lucas Schulz, Michael Pulia IntroductionCellulitis is commonly treated in the emergency department (ED). Oritavancin is a novel, broad-spectrum antibiotic which provides an entire treatment course for cellulitis with one dose. However, optimal ED prescribing scenarios for oritavancin have not been well defined. The purpose of this study was to identify a population of ED patients with cellulitis who would be most appropriate to receive oritavancin.MethodsThis was a descriptive, retrospective study conducted at a Midwest healthcare system with two EDs. Over a 1 year period, all adult patients admitted from the ED to an inpatient ward with an ICD-10 diagnosis for cellulitis were reviewed using a priori defined criteria to identify potentially avoidable admissions (PAA). Potentially avoidable admissions were further characterized and compared to the non-avoidable admission population. Identified patient-specific criteria for PAAs were used to develop oritavancin inclusion/exclusion criteria and a case selection flowchart.ResultsEighty-six patients were identified during the study period. Nine patients (10.5%) were deemed a PAA. A majority of the PAA population had at least one risk factor for treatment failure (55% with diabetes mellitus) and this group was significantly younger than the non-PAA group (42.2 vs 58.6 years; P = 0.01). There were no differences between the PAA group and the non-PAA group in regard to non-age demographics, other risk factors for outpatient treatment failure, comorbidities, or length of stay.ConclusionOritavancin is an outpatient treatment alternative for cellulitis patients whose only justification for planned admission is the presence of one or more risk factors for treatment failure.
       
  • Does intramuscular ondansetron have an effect on intramuscular
           ketamine-associated vomiting in children' A prospective, randomized,
           double blind, controlled study
    • Abstract: Publication date: Available online 12 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Amir Nejati, Seyyedhossein Seyyedhoseini Davaraani, Mohammad Taghi Talebian, Firouzi Hossein, Hamideh Akbari ObjectiveThis study was conducted to determine the effect of intramuscular ondansetron on ketamine-associated vomiting in children undergoing procedural sedation.MethodsThis randomized, double-blind, placebo-controlled, parallel-group clinical trial was conducted at the emergency departments of two university-affiliated tertiary care hospitals. Eligible participants included all 6-month to 16-year-old children who received IM ketamine for PSA in the ED. A convenience sampling approach was used and a block randomization method was applied (blocks of four) using a computer-generated random sequence. Patients received ketamine 4 mg/kg or ketamine 4 mg/kg plus ondansetron 0.1 mg/kg intramuscularly. All findings including the occurrence of vomiting and its frequency were then recorded in the data collection sheets.ResultsOf 56 patients who received ondansetron plus ketamin, 7 (12.5%) and 1 (1.8%) experienced vomiting during recovery and before discharge and Of 65 patients in the control group, 14 (21.5%) and 6 (9.2%) experienced vomiting during recovery and before discharge, respectively. The observed differences in the rates of vomiting during recovery and at discharge were statistically significant between the two groups (P-value of 0.03 and
       
  • A review of the characteristic of “Grit” for emergency medicine
           resident selection and training: Making the intangible tangible'
    • Abstract: Publication date: Available online 12 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Michael J. Asken, Amy Wyatt, Courtney Devlin
       
  • Polyethylene glycol electrolyte lavage solution increases tablet
           dissolution of acetaminophen in an in vitro model mimicking acute
           poisoning
    • Abstract: Publication date: Available online 12 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Sean Patrick Nordt, Kimberly J. Won, Christian Tomaszweski, Richard F. Clark IntroductionPolyethylene glycol electrolyte lavage solution (PEG-ELS) is similar to pharmaceutical solvent propylene glycol and used following acute poisonings for whole bowel irrigation (e.g., “body stuffing”). This raises concern of PEG-ELS increasing solubility following acute ingestions of non-sustained release xenobiotics in the stomach. We theorized PEG-ELS increases solubility of acetaminophen in an in vitro stomach model.Material and methodsAn in vitro artificial stomach with 500 mL simulated gastric fluid and either 500 mL of sodium chloride 0.9% (group A) or 500 mL of PEG-ELS (group B). Ten non-sustained release acetaminophen tablets added with concentrations 0, 15, 45 and 90 min in triplicate. Mean concentrations and mean area under the curve (AUC) (mg-min/L to 90 min).ResultsIn control group A (normal saline + simulated gastric fluid) mean acetaminophen concentrations 0, 3, 13 and 36 mg/L at 0, 15, 45 and 90 min, respectively. In group B (PEG-ELS + simulated gastric fluid) mean acetaminophen concentrations 0, 34, 109 and 136 mg/L at 0, 15, 45 and 90 min, respectively (p 
       
  • Pelvic organ prolapse: An unusual cause of small bowel obstruction
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): K. Hope Wilkinson, Arielle Thomas, Jillian Theobald We present the rare case of a small bowel obstruction secondary to pelvic organ prolapse (POP). A 77-year-old female presented with four days of abdominal pain, nausea, and vomiting. She had a history of abdominal hysterectomy with bilateral salpingo-opherectomy and a mildly symptomatic cystocele. She was found to have an enterocele causing small bowel obstruction. The enterocele was manually reduced and subsequently managed non-operatively with a pessary. Prior case reports of small bowel obstructions secondary to POP required emergent surgical intervention. Post-menopausal women should be asked about symptoms or presence of pelvic organ prolapse and in the correct patient population, pelvic examination can be important for diagnosis and treatment of small bowel obstruction. If the enterocele is manually reduced non-operative management can be safe and effective.
       
  • Simply influenza A (H3N2)-associated encephalitis with seizure
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Hao-Tang Yuan, Tsung-Han Ho, Jiunn-Tay Lee, Po-Chuan Chen, Chih-Wei Wang, Fu-Chi Yang Influenza-associated acute encephalopathy (IAE) is more prevalent in children than in adults and often results in neurological sequelae or even death. Diagnosis of IAE is difficult as clinical presentation varies significantly and the influenza virus is rarely detected in cerebrospinal fluid. Moreover, seizures in adults due to influenza infection are rare. Herein, we describe the case of an adult presenting with both acute encephalitis and seizures.A 38-year-old female was admitted to the emergency department with acute respiratory symptoms and fever, followed by quick progression to stupor within 24 h. A rapid antigen test was influenza A-positive, and polymerase chain reaction of nasal secretions confirmed the H3N2 subtype. Brain magnetic resonance imaging showed bilateral water restriction lesions at the thalamus and the cerebellum and an electroencephalogram showed frequent episodic generalized sharp-and-slow waves over the bilateral frontal region. Based on the neuroimaging and laboratory findings, we diagnosed the patient with adult influenza A (H3N2)-related encephalitis complicated by seizure. Treatment with oseltamivir and anticonvulsants led to complete neurologic recovery by day 14.This report describes two unusual neurological manifestations of influenza A, i.e., encephalitis and seizures, in an adult. We emphasize that, in adults presenting with acute viral encephalitis, clinicians should consider influenza infection as part of the differential diagnosis, and that typical neuroimaging in conjunction with laboratory detection of influenza virus and/or intrathecal antibody production suggestive of IAE, may help establish an accurate diagnosis.
       
  • Sharing the sidewalk: A case of E-scooter related pedestrian
           injury
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): N. Sikka, C. Vila, M. Stratton, M. Ghassemi, A. Pourmand The popularity of rideshare electric scooters is due to their availability, accessibility, and low cost. The recent increase in electric scooter use has raised concerns regarding the safety of both riders and pedestrians. Previous studies characterize the incidence and pattern of injury for riders, but there is a lack of literature concerning electric scooters' impact on pedestrians. Pedestrians injured by electric scooters face potential financial burdens from hospitalization costs, medical interventions, taking time off from work, and rehabilitation therapies. Based on prior studies, pedestrians who are most prone to injuries sustained by pedestrian transportation include individuals with vision and/or hearing impairment, young children, the elderly, and people distracted by mobile devices. We present a case involving a sixty-year-old female pedestrian who presented to the emergency department with an acute lumbar compression fracture after a collision with an electric scooter. This study highlights the safety risks and incidence of injuries for pedestrians associated with electric scooters, which can help shape public policy to ensure the safety of both riders and pedestrians.
       
  • A dermatologic emergency; Sweet's syndrome
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Mustafa Korkut BackgroundSweet's syndrome (SS), also known as acute febrile neutrophilic dermatosis, is a rare condition characterized by recurrent erythematous skin lesions. Skin lesions appear as papules, nodules and plaques located on the upper extremity, trunk, neck and face.Case reportA 72-year-old male patient presented to the emergency department with a 10-day history of generalized rash, generalized muscle and joint pain and high fever. He had a history of upper respiratory tract infection. He presented with painful erythematous plaques on both lower and upper extremities and the trunk as well as serohemorrhagic bullous lesions on the feet. The laboratory results revealed WBC count of 20.6 × 103/mm3 (76.9% neutrophils), CRP (c-reactive protein) of 33 mg/L and erythrocyte sedimentation of 110/h. The patient was referred to a dermatologist with prediagnosis of SS due to the presence of typical painful skin lesions, high fever and neutrophilic leukocytosis. A systemic corticosteroid therapy was initiated. The diagnosis for SS was confirmed after the skin biopsy revealed the presence of dense dermal infiltrate of neutrophils and leukocytoclasis in the upper dermis. The patient responded rapidly to corticosteroids and the skin lesions improved.ConclusionWe reported this case as it was a rare life-threatening dermatosis diagnosed in the emergency department, which is generally difficult to diagnose therein, and the skin lesions appeared on the lower extremities.
       
  • Vancomycin-induced Kounis Syndrome
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Caleb Leibee, Bahrenegash Getachew, Michael R. Ehmann Kounis Syndrome is a rare allergic reaction that results in coronary vasospasm and may occur in patients with and without coronary artery disease. A 57-year-old man receiving pre-operative vancomycin for osteomyelitis and gangrene of the foot experienced an episode of anginal symptoms associated with transient ischemic 12-lead electrocardiogram (ECG) changes. The patient's symptoms and ECG changes abated with discontinuation of vancomycin and subsequent coronary angiography revealed no evidence of coronary artery disease. Treatment of Kounis Syndrome begins with cessation of the causative agent. Consensus guidelines for the management of Kounis Syndrome have not been established but treatment should both dilate the coronary vessels and suppress the allergic response. Coronary vasospasm after administration of antibiotics, including vancomycin, is a rare but serious reaction. It is important that Emergency Physicians recognize Kounis Syndrome as an uncommon yet dramatic and consequential reaction to such a commonly-administered antibiotic.
       
  • Emergency department presentation of ‘delusional parasitosis by
           proxy’. Delusional parent, injured child
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Jay D. Fisher We report a case of 'delusional parasitosis by proxy'. A sixyear old child was brought to the emergency department by a mother with concerns that her son had a skin and scalp infestation. Despite the absence of any clinical findings being found on exam, the mother remained disproportionately concerned. Follow up care was recommended with the child's primary care. The mother returned to the ED with her child three weeks later with concerns that her son had an inflamed scalp and eyes. The mother remained insistent that the child was infested with bugs and she had sought care at two other locations where the child was prescribed permethrin on both visits. She had been applying the medication repeatedly. On exam the boy's scalp had been shaved and was erythematous and irritated; his eyebrows and eyelashes had also been shaved off and likely contributed to an irritant conjunctivitis from repeated applications of topical permethrin lotion. No evidence of infestation was identified. We recruited the assistance of the maternal grandparents, child protective services and primary care pediatrics and the child was removed from the mother's custody and placed into the custody of the grandparents. Six weeks later with basic skin care and erythromycin ophthalmic ointment for the eyes, the child's hair, eyebrows and eyelashes grew had grown in, and the scalp irritation had resolved. The mother had sought and received psychiatric care and was improving.
       
  • Antibiotics with nasal packing—The authors reply
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Tiffany Murano
       
  • Commentary on prophylactic systemic antibiotics for anterior epistaxis
           treated with nasal packing in the emergency department
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Zhengcai Lou
       
  • Comments on GEDI vs. CVP goal-directed fluid resuscitation for chronic
           obstructive pulmonary disease patients with septic shock: A randomized
           controlled trial
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Hairong Cai, Shuling Liu, Weizhang Zhang, Lieyuan Zhang, Jing Zeng, Shuai Zhao, Xingui Cai, Yongning Guo, Zhishang Li, Bojun Chen
       
  • Methamphetamine psychosis: Lack of association with stimulant prescription
           ADHD medications
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Dennis M. Mann, Catherine A. Marco, John P. Detherage, Peter J. Greene, Daniel E. Ross
       
  • Which of hemodialysis and direct hemoperfusion is more recommended for
           treating severe caffeine poisoning'
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Tomohiro Yoshizawa, Yoshito Kamijo, Tomoki Hanazawa, Yoshiki Suzuki, Yuji Fujita, Kiyotaka Usui, Sumio Hirata, Tohru Kishino
       
  • Carbon monoxide poisoning at a Florida Hospital following Hurricane Irma
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Jeffrey G. Klein, Scott M. Alter, Richard J. Paley, Patrick G. Hughes, Lisa M. Clayton, William Benda, Richard D. Shih, Joshua J. Solano
       
  • If we build it they will come patient use of health portals
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): La Vonne A. Downey, Amanda Hong, Karina Herrera
       
  • Suicidal ideation in the elderly: Psychosocial risk factors and
           precipitants
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Lindsey Ouellette, Allison Cook, Keegan Michel, Leah Harvey, Chad Sutliffe, Todd Chassee, Jeffrey Jones
       
  • Current use and training needs of point-of-care ultrasound in emergency
           departments: A national survey of VA hospitals
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Jeremy S. Boyd, Charles M. LoPresti, Megan Core, Christopher Schott, Michael J. Mader, Brian P. Lucas, Elizabeth K. Haro, Erin P. Finley, Marcos I. Restrepo, Chad Kessler, Angel Colon-Molero, Jacqueline Pugh, Nilam J. Soni
       
  • Comments on GEDI vs. CVP goal-directed fluid resuscitation for COPD
           patients with septic shock: A randomized controlled trial
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Wenwei Feng, Xiaohan Ye, Hongxue Lv, Chijun Hou, Jianxing Chen, Yingjun Chen, Yanjin Zeng, Zhiyuan Su
       
  • Reply to the letter entitled “Risk Stratification and Timing for
           Invasive Approach in Patients with non-STEMI”
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): James R. Langabeer, Tiffany Champagne-Langabeer, Raymond Fowler, Timothy Henry
       
  • Risk stratification and timing for invasive approach in patients with
           non-STEMI
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Kadir Uğur Mert, Gurbet Özge Mert
       
  • Lack of associations of substance use and mental health with self-reported
           pain scores among emergency department patients
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Catherine A. Marco, Dennis Mann, Christian Daahir, Harry Savarese, John Paul Detherage, Cameron McGlone
       
  • Barriers and facilitators for emergency department initiation of
           buprenorphine: A physician survey
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Margaret Lowenstein, Austin Kilaru, Jeanmarie Perrone, Jessica Hemmons, Dina Abdel-Rahman, Zachary F. Meisel, M. Kit Delgado
       
  • Nursing driven approaches to improving emergency department discharge
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Anish K. Agarwal, Sean Foster, Carolina Garzon Mrad, Brooks Martino, Christopher K. Snider, Leighann Mazzone, Allen Fasnacht, Kelly Patton, Christopher Edwards, John Flamma
       
  • The influence of sertraline on depressive disorder after traumatic brain
           injury: A meta-analysis of randomized controlled studies
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Caibin Gao, Qiang Fu, PeiPei Chen, Zhongtao Liu, Qingjiu Zhou BackgroundSertraline showed some potential in alleviating depressive disorder after traumatic brain injury. This systematic review and meta-analysis was conducted to investigate the efficacy of sertraline on the treatment of depressive disorder after traumatic brain injury.MethodsThe databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched for collecting the randomized controlled trials (RCTs) regarding the efficacy of sertraline for traumatic brain injury.ResultsThis meta-analysis included five RCTs. The initial use of sertraline was within 8 weeks after traumatic brain injury. Compared with control group for traumatic brain injury, sertraline treatment showed no significant improvement on Hamilton Depression Rating Scale (HAM-D) (standard mean difference (Std. MD) = −0.08; 95% confidence interval (CI) = −0.45 to 0.28; P = 0.65), anxiety score (Std. MD = 0.08; 95% CI = −0.32 to 0.48; P = 0.69), aggression score (Std. MD = −0.12; 95% CI = -0.56 to 0.32; P = 0.59), or quality of life (QOL) score (Std. MD = −0.06; 95% CI = −0.49 to 0.37; P = 0.78). There was no statistical difference of diarrhea (risk ratio (RR) = 0.85; 95% CI = 0.92 to 3.71; P = 0.08), dizziness (RR = 1.15; 95% CI = 0.57 to 2.31; P = 0.70), dry mouth (RR = 2.44; 95% CI = 0.43 to 13.89; P = 0.32), nausea or vomiting (RR = 1.17; 95% CI = 0.37 to 3.70; P = 0.79) between sertraline group and control group.ConclusionsSertraline showed no obvious benefits for the relief of depressive disorder after traumatic brain injury.
       
  • Safety preempted: When EMTALA and restraining orders collide
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Michael R. MacIntyre, Jacob M. Appel
       
  • Optimizing the month of the year backwards test for delirium screening of
           older patients in the emergency department
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Wolfgang Hasemann, Florian F. Grossmann, Roland Bingisser, Martina Hafner, Dieter Breil, Reto W. Kressig, Christian H. Nickel IntroductionDifferent scoring methods exist for the Month of the Year Backward Test (MBT), which is designed to detect inattention, the core feature of delirium. When used as a part of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED), each error in the MBT scores one point. Because this scoring procedure is complex, we aimed to simplify the scoring method of the MBT.MethodsThis is a secondary analysis of a single center prospective validation study of the mCAM-ED comprising a sample of Emergency Department (ED) patients aged 65 or older presenting to our ED.Data collectionResearch assistants (RAs) who were trained nurses conducted the MBT. Geriatricians conducted the reference standard delirium assessment within 1 h of the RA.ResultsFor the scoring method “number of errors”, optimal performance according the Youden index was achieved when 8 or more errors were reached resulting in an overall sensitivity of 0.95 and overall specificity of 0.94. The scoring method “number of errors in combination with time needed” resulted in a comparable result with minimally lower positive likelihood ratios. For the scoring method “last month in correct order”, optimal performance according the Youden index was achieved with the month of September resulting in an overall sensitivity of 0.90 and an overall specificity of 0.89.DiscussionWe suggest omitting the factor time and using a more practical scoring method with good performance: “last month in correct order” with the requirement to reach September to rule out delirium.
       
  • The impact of a multidisciplinary algorithmic approach to acute lower
           gastrointestinal bleeding
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Matthew Petersile, Mustafa Haroon, Dimitri Belkin, Adlin Pinheiro, Janice Weinberg, Hemant K. Roy, Brian C. Jacobson
       
  • Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic
           intussusception
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Brian L. Park, Joni E. Rabiner, James W. Tsung BackgroundIdentification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS.MethodsWe conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated.ResultsED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35–76 months) for SB-SBI and 8 months (IQR 5.8–13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p 
       
  • Multiple boluses of alteplase followed by extracorporeal membrane
           oxygenation for massive pulmonary embolism
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Irene Li, Arielle Filiberti, Robert Mokszycki, Gayle Galletta Thrombolytics and extracorporeal membrane oxygenation (ECMO) are potential management options for massive pulmonary embolism (PE). There are early data supporting the use of repeated alteplase 50 mg bolus for massive PE. However, there is sparse literature addressing placement of ECMO catheters after systemic thrombolysis, and there are no reports of initiating ECMO after repeated bolus of alteplase. We present the case of a patient with massive PE who received two boluses of alteplase for recurrent cardiac arrest, followed by initiation of ECMO. The patient stabilized with these interventions, and ultimately had a good outcome with normal neurologic and functional status.
       
  • Utility of applying white blood cell cutoffs to non-diagnostic MRI and
           ultrasound studies for suspected pediatric appendicitis
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Thomas M. Kennedy, Amy D. Thompson, Arabinda K. Choudhary, Richard J. Caplan, Kathleen E. Schenker, Andrew D. DePiero BackgroundNon-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs).MethodsA retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of
       
  • A study of time saved by emergency medicine physicians through working
           with clinical pharmacists in the emergency department
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Justin Grill, Caleb Bryant, Kyle Markel, Samuel J. Wisniewski PurposeTo describe quantitatively the impact on physician efficiency when an Emergency Medicine Clinical Pharmacist (EMCP) is available to Emergency Department (ED) physicians while working under a collaborative care agreement in a Michigan-based Health System.MethodsFour EMCPs each logged and categorized their time during 14 ten hour shifts, for a total of 56 shifts or 560 total hours worked. There were nine categories observed including: culture call back, urine, blood, or other culture follow up, antibiotic changes, patient call-backs, pharmacy call backs, critically ill, and general questions.ResultsEMCPs saved ED physicians an average of 75 min per shift, with the highest yield categories being general questions (25.2 min per shift (mps), standard error (SE) = 2.67), critically ill patient service (11.5 mps, SE = 2.66), and urine culture follow-ups (11.3 mps, SE = 1.05).ConclusionsEMCPs in the ED save physicians a significant amount of time per shift, and categorically the most time saved was in fielding general questions, time spent with critically ill patients, and following up on urine cultures. The time saved by physicians could translate into more patients seen per shift.
       
  • The association between seatbelt use and trauma outcomes: Does body mass
           index matter'
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Adel Elkbuli, Brianna Dowd, Paul J. Spano, Shaikh Hai, Dessy Boneva, Mark McKenney BackgroundNational Highway Traffic Safety Administration (NHTSA) reports that seat belt use results in a significant decrease in MVC mortality. The rate of obesity is currently extensive. There is limited data on the impact of seat belt use and body mass index (BMI) on mortality and trauma outcomes following MVCs. This study aimed to evaluate the impact of seat belt use and BMI on outcomes in adult trauma patients.MethodsA four-year review using our Level I Trauma Center registry. Patients were divided by BMI into normal weight BMI 
       
  • Effect of hypoxia on mortality and disability in traumatic brain injury
           according to shock status: A cross-sectional analysis
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Dong Eun Seo, Sang Do Shin, Kyoung Jun Song, Young Sun Ro, Ki Jeong Hong, Jeong Ho Park ObjectivesThis study aimed to test the association between hypoxia level and outcomes according to shock status in traumatic brain injury (TBI) patients.MethodsAdult TBI patients transported by emergency medical services in 10 provinces were enrolled. Hypoxia was a main exposure; three groups by oxygen saturation (SaO2, non-hypoxia (≥94%), mild hypoxia (90 ≤ SaO2 
       
  • Is repeat head CT necessary in patients with mild traumatic intracranial
           hemorrhage
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Jonathan Van Ornam, Peter Pruitt, Pierre Borczuk BackgroundPatients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.MethodsThis was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.ResultsOf these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.ConclusionsRHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.
       
  • A National Dataset Analysis of older adults in emergency department
           observation units
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Lauren T. Southerland, Katherine M. Hunold, Christopher R. Carpenter, Jeffrey M. Caterino, Lorraine C. Mion BackgroundEmergency Department (ED) Observation Units (Obs Units) are prevalent in the US, but little is known regarding older adults in observation. Our objective was to describe the Obs Units nationally and observation patients with specific attention to differences in care with increasing age.DesignThis is an analysis of 2010–2013 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national observational cohort study including ED patients. Weighted means are presented for continuous data and weighted percent for categorical data. Multivariable logistic regression was used to identify variables associated with placement in and admission from observation.ResultsThe number of adult ED visits varied from 100 million to 107 million per year and 2.3% of patients were placed in observation. Adults ≥65 years old made up a disproportionate number of Obs Unit patients, 30.6%, compared to only 19.7% of total ED visits (odds ratio 1.5 (95% CI 1.5–1.6), adjusting for sex, race, month, day of week, payer source, and hospital region). The overall admission rate from observation was 35.6%, ranging from 31.3% for ages 18–64 years to 47.5% for adults ≥85 years old (p 
       
  • Clinical management decisions for adults with prolonged acute cough:
           Frequency and associated factors
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Christian S. Marchello, Mark H. Ebell, Brian McKay, Ye Shen, Eric T. Harvill, Christopher C. Whalen BackgroundUncomplicated episodes of prolonged acute cough are usually viral and self-limited, but despite evidence and recommendations to the contrary, they are often treated with antibiotics.MethodsMixed cross-sectional and prospective observational study of adults 18 years or older presenting to two urgent care centers with a cough of 7 to 56 days as their chief complaint. Factors associated with cough duration and clinical decisions were analyzed by univariate and multivariate logistic regression.ResultsOf the 125 enrolled patients, 118 (94%) received an antibiotic, 97 (78%) a cough suppressant, 87 (70%) a systemic corticosteroid, and 39 (31%) a chest X-ray (CXR). Longer duration of cough was associated with the presence of self-reported wheezing or noises (adjusted odds ratio 6.29, 95% CI 1.36–29.16) while the presence of both wheezing and crackles on a clinician chest exam was associated with shorter duration (aOR 0.03, 95% CI 0.00–0.27). A clinician was more likely to order a CXR in patients with dyspnea (aOR 3.01, 95% CI 1.21–7.49), less likely to prescribe a systemic corticosteroid in patients with crackles (aOR 0.27, 95% CI 0.09–0.82), and more likely to prescribe a cough suppressant to older patients (1.04 per additional year of age, 95% CI 1.01–1.07).ConclusionsSystemic corticosteroids and cough suppressants are being prescribed at high rates in patients with uncomplicated acute cough in the urgent care setting. Additional studies to determine if similar rates are seen in other urgent care centers, or in other contemporary ambulatory settings are warranted.
       
  • Can corticosteroids reduce the mortality of patients with severe
           sepsis' A systematic review and meta-analysis
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Yue-Nan Ni, Yuan-Ming Liu, Yi-Wei Wang, Bin-Miao Liang, Zong-An Liang BackgroundThe effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo.MethodsPubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock.ResultsA total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85–0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85–0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89–1.00, Z = 1.93, P = 0.05), or occurrence (RR 0.83, 95% CI 0.56–1.24, Z = 0.90, P = 0.37) or reoccurrence of septic shock (RR 1.08, 95% CI 1.00–1.16, Z = 1.89, P = 0.06).ConclusionsCorticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.
       
  • External validation of a clinical prediction rule for very low risk
           pediatric blunt abdominal trauma
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Elise Springer, S. Barron Frazier, Donald H. Arnold, Adam A. Vukovic BackgroundComputed tomography (CT) is frequently used to identify intra-abdominal injuries in children with blunt abdominal trauma (BAT). The Pediatric Emergency Care Applied Research Network (PECARN) proposed a prediction rule to identify children with BAT who are at very low risk for clinically-important intra-abdominal injuries (CIIAI) in whom CT can be avoided.ObjectiveTo determine the sensitivity of this prediction rule in identifying patients at very low risk for CIIAI in our pediatric trauma registry.MethodsRetrospective review of our institutional trauma registry to identify patients with CIIAI. CIIAI included cases resulting in death, therapeutic intervention at laparotomy, angiographic embolization of intra-abdominal arterial bleeding, blood transfusion for intra-abdominal hemorrhage, and administration of intravenous fluids for two or more nights for pancreatic or gastrointestinal injuries. Patients were identified using ICD diagnosis and procedure codes. Kappa was calculated to evaluate inter-reviewer agreement.ResultsOf 5743 patients, 133 (2.3%) had CIIAI. 60% were male and the mean age was 8 (SD 4.4) years. One patient with CIIAI met the proposed very low risk criteria, resulting in a prediction rule sensitivity of 99%, 95% CI [96–100%]. This patient also had extra-abdominal arterial bleeding requiring revascularization, offering an alternative reason for transfusion. Kappa was 0.85, 95% CI [0.82, 0.89], indicating strong inter-rater agreement.ConclusionsOne out of 133 patients with CIIAI met very low risk criteria based on the PECARN prediction rule. This study supports the PECARN clinical prediction rule in decreasing CT use in pediatric patients at very low risk for CIIAI.
       
  • Using spatial regression methods to evaluate rural emergency medical
           services (EMS)
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Zhaoxiang He, Xiao Qin, Ralph Renger, Eric Souvannasacd Emergency Medical Services (EMS) are acute services provided outside of the hospital. EMS are crucial in rural environments where hospitals are often far away and difficult to access. Establishing EMS performance measures is critical in improving a rural community's access to these services and eliminating systemic inequalities. However, an absence of data leads to challenges in developing objective and quantifiable service metrics. EMS data are regularly collected through the National EMS Information System (NEMSIS), yet the manner of data collection and quality of data vary across agencies. Moreover, the amount and complexity of information makes data analyses difficult, subsequently effecting EMS leaderships' ability to identify improvement needs.This study used NEMSIS data to exemplify approaches for establishing two data-driven performance measures. The measures used in this study – timely service and service coverage – are both dependent on the mobility and accessibility of the EMS transportation network. Two types of spatial models: the spatial econometric model and geographically weighted regression (GWR) model, were developed and then compared to the linear regression model to help identify response time factors. GWR performed best in terms of goodness-of-fit statistics and was chosen to help understand how factors (e.g., weather, transportation) impact the timely provision of EMS in rural areas. The GWR results provided additional insights through the particular spatial patterns of the coefficient estimates and their statistical significance to EMS practitioner for their references to reduce local response times.
       
  • Intranasal ketamine reduces pain of digital nerve block; a double blind
           randomized clinical trial
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Amir Nejati, Mohammad Jalili, Saeed Abbasi, Farhad Talebi Sarwari, Ali Bidari, Mahsa Ghajarzadeh, Atousa Akhgar BackgroundLow dose ketamine can be used as analgesic in acute pain management in the emergency department (ED).ObjectiveEfficacy of IN ketamine in acute pain management in the ED.MethodThis is a double blind randomized clinical trial on patients older than 15 years who needed digital nerve block (DNB). Participants randomly received IN Ketamine (1 ml = 50 mg) or placebo (normal saline, 1 ml) 5 min before DNB. In both groups, patients' pain score was recorded by visual analogue score (VAS) at baseline, after DNB and 45 min after completion of DNB. Adverse effects of ketamine and changes in vital signs were also recorded and compared with placebo group.ResultsA total number of 100 patients were enrolled in the study with the median (IQR) age of 36.5 (26) years, including 65 men and 35 women. IN ketamine resulted in less pain compared to placebo after performing DNB and 45 min after the procedure. Median (IQR) basic VAS score was 50 (15) in ketamine group, and 49 (27) in control group. Median (IQR) block pain VAS score was 28.5 (19) in ketamine group and 47.5 (31) in control group. Median (IQR) procedural pain VAS score was 21.5 (16) in ketamine group and 43.5 (29) in control group. Only 7 patients had adverse effects in either group.ConclusionThe findings of this study suggest that IN ketamine can be effective in reducing pain in patients with acute pain, without adding significant side effects.
       
  • Efficacy and outcomes of lipid resuscitation on organophosphate poisoning
           patients: A systematic review and meta-analysis
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Shiyuan Yu, Shanshan Yu, Lili Zhang, Yanxia Gao, Joseph Walline, Xin Lu, Yong Ma, Huadong Zhu, Xuezhong Yu, Yi Li ObjectiveOrganophosphate (OP) pesticides are still widely available in developing countries, leading to numerous accidental or suicidal poisonings every year. Lipid emulsion treatments are commonly used in resuscitating OP poisoning patients but few studies regarding their use have been reported. Our meta-analysis aimed to analyze the efficacy and outcomes of lipid resuscitation on OP poisoning patients.MethodsA systematic search for associated studies was conducted in Pubmed, EMBASE, MEDLINE, the Cochrane Library and the Chinese National Knowledge Infrastructure. Collected data was pooled using Revman v5.3. Outcomes included prognosis (cured vs. mortality rates), hepatic function (serum ALT, AST, Total Bilirubin (TBIL) level), serum acetylcholinesterase (AchE) level and respiratory function (rate of respiratory muscular paralysis).ResultsSeven randomized controlled studies consisting of 630 patients meeting inclusion criteria were identified. Lipid emulsion helped to improve the cure rate [OR = 2.54, 95% CI (1.33, 4.86), p = 0.005] and lower the mortality rate [OR = 0.31, 95% CI (0.13, 0.74), p = 0.009]. Serum ALT, AST and TBIL in patients undergoing lipid resuscitation were lower than those in the control groups [ALT, SMD = −1.52, 95% CI (−2.64, 0.40), p = 0.008; AST, SMD = −1.66, 95% CI (−3.15, 0.16), p = 0.03; TBIL, SMD = −1.26, 95% CI (−2.32, 0.20), p = 0.02]. Serum AchE level were increased in patients treated with lipid emulsion [SMD = 2.15, 95% CI (1.60, 2.71), p 
       
  • Efficacy of the presence of an emergency physician in prehospital major
           trauma care: A nationwide cohort study in Japan
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Yohei Hirano, Toshikazu Abe, Hiroshi Tanaka PurposeThe beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients.MethodsThis retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs.ResultsA total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival.ConclusionsOur results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.
       
  • Successful use of the two-tube approach for the treatment of phenobarbital
           poisoning without hemodialysis
    • Abstract: Publication date: September 2019Source: The American Journal of Emergency Medicine, Volume 37, Issue 9Author(s): Atsushi Tanikawa, Satoshi Seki, Takuya Yasuda, Eiju Hasegawa Half-life of the antipsychotic vegetamin is very long, partially due to the presence of phenobarbital, and mortality due to phenobarbital poisoning is high. Here, we present the case of a 22-year-old female admitted to the emergency department with disturbed consciousness due to vegetamin overdose. Her blood phenobarbital level was elevated to 123 μg/ml. Phenobarbital undergoes enterohepatic circulation, and its retention in the intestine causes its blood levels to remain sustained. The utility of hemodialysis for drug poisoning has been previously reported; however, its efficiency is not yet established and its efficacy is low for drugs with long half-lives such as phenobarbital. Therefore, we performed a two-tube approach to adsorb phenobarbital in the intestines with activated charcoal delivered via a gastric tube and to remove the phenobarbital-adsorbed activated charcoal using whole bowel irrigation via an ileus tube 2 h later. The patient successfully eliminated the charcoal via stool, the blood phenobarbital level decreased drastically without hemodialysis, and the clinical course improved. We propose that this two-tube approach is suitable for treatment of poisoning with drugs that undergo enterohepatic circulation and have long half-lives.
       
 
 
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