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Publisher: Elsevier   (Total: 3184 journals)

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Showing 1 - 200 of 3184 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 37, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 100, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 40, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 6)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 7)
Acta Astronautica     Hybrid Journal   (Followers: 434, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 28, 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: 3, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 308, 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: 1, SJR: 1.793, CiteScore: 6)
Acta Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
Acta Psychologica     Hybrid Journal   (Followers: 25, 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: 184, 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: 29, 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: 11, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 11, 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: 33, 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: 10, 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: 51, 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: 10, 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: 24)
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: 36, 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: 12, 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: 24)
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: 18)
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: 66)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 1, 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: 420, 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: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 53, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 382, 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: 472, 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: 45, 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: 7, 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: 11)
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: 10, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 54, 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: 63, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 46, 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: 249, 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: 66, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 24, 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: 208, 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: 218, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 6, 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: 46  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0735-6757
Published by Elsevier Homepage  [3184 journals]
  • 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 
       
  • Incidence and significance of injuries on secondary CT imaging after
           initial selective imaging in blunt trauma patients
    • Abstract: Publication date: Available online 11 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Richard Byrne, Aimee Parks, Joshua P. Hazelton, Michael Kirchhoff, Brian W. Roberts ObjectiveIt is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.MethodsThis was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system. Inclusion criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.Results537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).ConclusionWhile a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.
       
  • Topical tranexamic acid (TXA) for the management of a bleeding
           arteriovenous fistula
    • Abstract: Publication date: Available online 11 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Maria Loren Eberle, Elissa M. Schechter-Perkins, Zaid Altawil Tranexamic acid (TXA) is increasing in use in the Emergency Department (ED). While its topical uses have largely been observed in the management of epistaxis, other applications are utilized. We present a case of an 84 year old male with a bleeding arteriovenous fistula, responsive to topical application of tranexamic acid. This case report demonstrates another novel application of TXA in emergency care.
       
  • Impact of scribes on throughput metrics and billing during an electronic
           medical record transition
    • Abstract: Publication date: Available online 10 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Heather A. Heaton, Emily J. Schwartz, Wyatt J. Gifford, Karen A. Koch, Christine M. Lohse, Ryan J. Monroe, Kristine M. Thompson, Laura E. Walker, Thomas R. Hellmich ObjectiveEvaluate an established scribe program on throughput and revenue capture in an Emergency Department (ED) undergoing an EMR transition.MethodsA prospective cohort design comparing patients managed with and without scribes in an academic ED. Throughput metrics (medians, min) and relative value units (RVUs, means) were collected. Data was evaluated in its entirety (three months), as well as in two subsets: go live (immediate two weeks) and adoption (two weeks post implementation to end).ResultsAll patients: There was no significant difference in throughput or RVUs during the three month period. During go-live, scribes showed improvement in total RVUs per patient (4.63 vs 4.40, p = 0.048). During adoption, scribed patients had decreased length of stay (LOS, 221 vs 231, p = 0.023).Adults: Door to provider (28 vs 37, p = 0.014) and total RVUs (5.20 vs 4.92, p = 0.042) were improved with scribes in the go-live period. Scribes improved go-live morning and overnight shifts, while lengthening provider to disposition during afternoon shifts. No significant differences were seen in the adoption period, except for increased provider to disposition time overnight with scribes (154 vs 146, p = 0.030). Pediatrics: When all pediatric patients were compared, scribe patients had a decreased professional RVU charge (2.78 vs 2.90, p = 0.037). During go live and adoption, no significant differences were found in any other parameter or subgrouping.ConclusionsA scribe's ability to mitigate operational inefficiencies introduced by an EMR transition seems limited in an academic hospital. Previous research highlighting the impact of scribes on revenue was not replicated during this study.
       
  • Does a dose relationship exist with prothrombin complex and factor Xa
           inhibitor reversal' An alternate perspective of Yohe et al.
    • Abstract: Publication date: Available online 6 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Brian W. Gilbert, J. Spencer Dingman, Jacob A. Reeder, Steven M. Le, Paola J. Ponce, George J. Philip
       
  • An alternative plane block for multiple rib fractures: Rhomboid
           Intercostal and Sub-Serratus block (RISS)
    • Abstract: Publication date: Available online 6 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Ahmet Murat Yayik, Muhammed Enes Aydin, Erdal Tekin, Ali Bilal Ulas, Ali Ahiskalioglu Rib fractures are a common injury, which occur after severe blunt chest trauma. Sufficient and early pain control is essential to avoid respiratory complications. In recent years, the serratus plane and the erector spinae plane blocks have been used in ED for pain related to rib fractures. The Rhomboid Intercostal and Sub-Serratus (RISS) block can be utilized for pain control in patients with multiple rib fractures. We report two cases of patients with multiple rib fractures in which pain reduction was achieved with application of the RISS block.
       
  • Sepsis induced bacterial peritonitis caused by Granulicatella
           adiacens
    • Abstract: Publication date: Available online 6 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Zane Elfessi, Erica Liu, Yelena Dukarevich, Kaylee Caniff, Katrina Marquez, Zaheera Shabbir
       
  • A weighty matter: Obtaining and documenting pediatric weight in the
           emergency department
    • Abstract: Publication date: Available online 5 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Ashley A. Foster, Emory M. Petrack, Krislyn M. Boggs, Ashley F. Sullivan, Carlos A. Camargo, Joyce Li
       
  • Reassessment of violence toward emergency medicine physicians in Michigan
    • Abstract: Publication date: Available online 4 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Hamzeh Omar, Rebecca Yue, Amanda Amen, Terry Kowalenko, Bradford L. Walters
       
  • Use of meropenem to treat valproic acid overdose
    • Abstract: Publication date: Available online 4 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Diane Dreucean, Kevin Beres, Afton McNierney-Moore, Dante Gravino Overdose of valproic acid (VPA) or its derivatives can cause significant toxicities such as hyperammonemia or altered mental status. While levocarnitine has been used historically to manage VPA-associated hyperammonemia, no standard of therapy exists to manage VPA toxicity. We present a case of VPA overdose managed with meropenem in addition to levocarnitine. A 38-year old female presented to the emergency department after intentionally ingesting 20 tablets of extended release divalproex sodium. She received a 4-gram loading dose of levocarnitine. She developed altered mental status, and a repeat VPA level yielded a result of 278 μg/mL. She was given 1 g of meropenem and her subsequent VPA level was 193 μg/mL. Approximately 8 h after the initial dose, another 1 g of meropenem was administered. Additionally, she received 1 g of levocarnitine every 4 h for a total of six doses. A repeat VPA level returned at 62 μg/mL. The patient was transferred to the intensive care unit for further management. Carbapenem antibiotics inhibit acylpeptide hydrolase in the gastrointestinal tract. Inhibition of this enzyme prevents the reabsorption of metabolized VPA and therefore causes increased elimination. Our patient demonstrated a rapid lowering of VPA levels after administration of meropenem.
       
  • Raising the index of suspicion for heart failure-related iron deficiency
    • Abstract: Publication date: Available online 4 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Oscar M.P. Jolobe
       
  • Prevalence of serious injuries in low risk trauma patients
    • Abstract: Publication date: Available online 3 September 2019Source: The American Journal of Emergency MedicineAuthor(s): Megha R. George, Moira Carroll, Reuben J. Strayer ObjectivesComputed tomography (CT) utilization is widespread in contemporary Emergency Departments (EDs). CT overuse leads to radiation exposure, contrast toxicity, overdiagnosis, and incidental findings. This study explores the prevalence of clinically significant injuries in patients identified as low-risk trauma patients (LRTPs) using newly created criteria that account for the patient's age, trauma mechanism, assessability (which relies on level of consciousness, intoxication, and neurologic deficits), vital signs and other evidence of hypoperfusion, bleeding risk, and past medical history.MethodsThis was a 6-month retrospective chart review of all LRTPs presenting to a level 1 trauma center in Queens, New York. Data abstraction was performed independently by two abstractors and discrepancies adjudicated by the senior author. Patients were identified using the hospital trauma registry and two reports, created by the researchers, identifying selected chief complaints and discharge diagnoses.Results750 patients were identified of which 352 (46.93%) received one or more CT scans. There were a total of 790 CT scans ordered, of which 731 (92.53%) were negative for acute injury. There were 13 clinically significant injuries of which only one (0.13%) required immediate intervention. There were no mortalities in this LRTP group.ConclusionThe incidence of clinically significant injuries in this population is very low and injuries requiring immediate intervention are even lower. CT utilization in LRTPs should be guided by an explicit consideration of benefit and harm for each patient.
       
  • Performance of cardiac troponins within the HEART score in predicting
           major adverse cardiac events at the emergency department
    • Abstract: Publication date: Available online 30 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Jack Wei Chieh Tan, Hong Jie Gabriel Tan, Sahlen Anders Olof, Khung Keong Yeo, Woon Loong Calvin Chin, Fei Gao, Eng Hock Marcus Ong, Chin Pin Yeo, Wai Yoong Ng, Swee Han Lim BackgroundThis study compared the performance of a single blood draw of high-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI) and conventional troponin I (cTnI) within a modified HEART score for predicting 30-day MACE at Emergency Department (ED) presentation, and established local reference norms for all three assays by determining the cut-off point which yielded the highest sensitivity and negative predictive value for acute myocardial infarction and 30-day MACE.MethodsThis single-center prospective cohort study recruited chest pain patients at the ED, whose hsTnT, hsTnI and cTnI were taken on admission. Subjects were classified into low and non-low risk group according to their modified HEART score, with MACE as the primary endpoint. Receiver-operating characteristic (ROC) curves were generated, area under the curves (AUCs) were calculated; the performance characteristics were determined.ResultsThe performance of modified HEART scores was comparable among the three assays for 30-day MACE (84.9–87.0% sensitivity, 95.6–96.0% NPV, 95%CI) and none of these had very high AUC and specificity (AUC 0.70–0.71, 53.7–56.7% specificity, 95% CI). The modified HEART score using a single blood draw of either hsTnT (3.9 ng/L), hsTnI (0.9 ng/L) or cTnI (0.0 ng/L) at presentation yielded a sensitivity of 100% for 30-day MACE.ConclusionThe modified HEART score using a single blood draw of either hsTnT, hsTnI or cTnI was equally effective in risk-stratifying chest pain patients for safe discharge. The theoretical cut-off points yielding 100% sensitivity are potentially useful (when achieved) for safely discharging low risk patients with undifferentiated chest pain in the ED.
       
  • Second-degree atrioventricular block in an adolescent with an acute
           alcohol intoxication
    • Abstract: Publication date: Available online 30 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Anita W. Lekx, Sjane Lingius, Dennis G. Barten Binge drinking adolescents often present to the emergency department with an alcohol intoxication. Known clinical signs of alcohol intoxications are impaired consciousness and vomiting, occasionally complicated by pulmonary aspiration. Emergency physicians are often not aware of the fact that excessive alcohol intake can also lead to atrioventricular (AV) conduction disturbances. We present a case of a second-degree AV block in an adolescent with an acute alcohol intoxication. The etiology of this condition is not well understood; possible explanations are reviewed in this manuscript.
       
  • Toluene toxicity presenting with hypokalemia, profound weakness and U
           waves in the electrocardiogram
    • Abstract: Publication date: Available online 27 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Edgar Francisco Carrizales-Sepúlveda, Raymundo Vera-Pineda, Raúl Alberto Jiménez-Castillo, Karla Belén Treviño-García, Alejandro Ordaz-Farías We present the case of a 25-year-old man with progressive limb weakness. His electrocardiogram showed prominent U waves which made us consider hypokalemia. The final diagnosis was toluene intoxication with severe hypokalemia and metabolic acidosis. Intravenous potassium administration and hydration effectively corrected the electrolyte and acid-base alterations; weakness resolved and the patient was discharged. The approach to a patient with acute weakness can be challenging. This case reminds us that the electrocardiogram can be a valuable tool in the evaluation and differential diagnosis of patients presenting to the emergency department with these conditions.
       
  • Audiovisual recording in the emergency department: Ethical and legal
           issues
    • Abstract: Publication date: Available online 27 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Kenneth V. Iserson, Nathan G. Allan, Joel M. Geiderman, Rebecca R. Goett Emergency physicians, organizations and healthcare institutions should recognize the value to clinicians and patients of HIPAA-compliant audiovisual recording in emergency departments (ED). They should promote consistent specialty-wide policies that emphasize protecting patient privacy, particularly in patient-care areas, where patients and staff have a reasonable expectation of privacy and should generally not be recorded without their prospective consent. While recordings can help patients understand and recall vital parts of their ED experience and discharge instructions, using always-on recording devices should be regulated and restricted to areas in which patient care is not occurring.Healthcare institutions should provide HIPAA-compliant methods to securely store and transmit healthcare-sensitive recordings and establish protocols. Protocols should include both consent procedures their staff can use to record and publish (print or electronic) audiovisual images and appropriate disciplinary measures for staff that violate them. EDs and institutions should publicly post their rules governing ED recordings, including a ban on all surreptitious or unconsented recordings. However, local institutions may lack the ability to enforce these rules without multi-party consent statutes in those states (the majority) where it doesn't exist. Clinicians imaging patients in international settings should be guided by the same ethical norms as they are at their home institution.
       
  • 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.
       
  • EMLA-induced methemoglobinemia after laser-assisted hair removal procedure
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Renata Portasio Lerner, Eric Lee This is the case of a 23-year-old female with a past medical history of ADHD and Depression who was evaluated in the emergency department for perioral cyanosis and hypoxia after application of the eutectic mixture of lidocaine and prilocaine (EMLA) local anesthetic prior to a laser-assisted hair removal procedure. This report illustrates a case of methemoglobinemia which is a rare but significant complication of topical anesthetic use.
       
  • A more simplified and practical loading dose formula for antidotal oral
           ethanol for toxic alcohols
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Frank P. Paloucek, Renee Petzel
       
  • Intubation and intensive care after laminaria anaphylaxis in
           second-trimester abortion
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Miriam McQuade, Kyle Barbour, Sarah Betstadt, Amy Harrington Laminaria are cervical dilators inserted for several days preceding second-trimester abortions and other uterine procedures. Our patient was intubated after a life-threatening anaphylactic reaction to laminaria prior to her surgical abortion. Abortions with laminaria dilators are frequently performed outpatient across the United States. Due to stigma, increasing restrictions, and forced closure of family planning clinics, these procedures are often obtained covertly and remotely. Patients may present obtunded, in shock, without records or proxy, and with no external evidence of the allergen's location or continued presence. Emergency and critical care physicians may consider this etiology in obtunded women with anaphylaxis who are responding poorly to standard care.
       
  • Inflammatory markers limitations in the diagnosis of pediatric calcaneal
           osteomyelitis
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Jared Ingersoll, Megan Halliday, Daniel J. Adams, Jonathan D. Auten, Daphne Morrison Ponce Calcaneal osteomyelitis is an uncommon, but clinically important emergent condition in the differential of the limping child. Early recognition is paramount to prevent complications from delayed diagnosis like formation of periosteal abscesses or growth plate injury. The diagnosis of pediatric osteoarticular infection relies on a combination of clinical exam, imaging and inflammatory markers. Erythrocyte sedation rate (ESR) and C-reactive protein (CRP) have reported sensitivities for osteomyelitis of 94% and 95%, respectively. However, clinicians should be aware that certain clinical factors can decrease the reliability of inflammatory markers in this pediatric condition. Location of infection in small bones like the calcaneus can lead to significantly lower sensitivities than in long bones. Pretreatment with antibiotics prior presentation can also decrease the reliability of ESR and CRP. In this case, we highlight two unique clinical factors that diminish the sensitivity of commonly used inflammatory markers in the diagnosis of pediatric osteomyelitis.
       
  • Massive emphysema after tooth extraction
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Yun Pan
       
  • A randomized blind controlled non-inferiority trial to compare the
           effectiveness of trigger point injections performed with normal saline
           (NS) and conventional active drug mix CADM in patients with myofascial
           pain syndromes
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Carlos J. Roldan, Uzondu Osuagwu, Marylou Cardenas-Turanzas, Billy K. Huh BackgroundMyofascial pain syndrome (MPS) originates in the muscle and fascia. MPS presents with referred pain specific for each muscle and a trigger point that reproduces the symptoms. Trigger-point-injection (TPI) is an effective approach to treating MPS. Some TPI agents, however, are associated with systemic and local side effects.ObjectiveThe aim of this study was to evaluate the effectiveness of TPI with a conventional active drug mixture (CADM) vs. that with normal saline solution (NS) alone in patients with MPS presenting to the emergency department (ED).MethodsAdults with MPS diagnosed in the ED, participants were randomly assigned to receive TPI with NS or with CADM. Pain intensity was scored using a 0–10 numeric rating scale prior to and after TPI, before discharge and 2 weeks after TPI.ResultsAmong 48 patients analyzed, 23 received TPI with NS. The mean pain scores were as follows: immediately before TPI, 7.59 (NS) and 7.44 (CADM); immediately after TPI, 2.22 (NS) and 1.76 (CADM); prior to discharge, 1.52 (NS) and 1.76 (CADM). At 2-week follow up, the mean pain scores were 4.29 (NS) and 4.14 (CADM). Pain was significantly reduced after TPI in both groups. At 2 weeks, the mean pain scores were similar between the groups. No adverse events were reported.ConclusionIn cases of MPS in the ED, pain can be controlled with TPI independent of the injectate. TPI with NS may be preferred over CADM because of its lower cost and more favorable side effect profile.
       
  • Esophageal bougienage in the emergency department with a substitute Hurst
           dilator
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Jovian Collins, Mark O. Tessaro, Terrance McGovern Impacted esophageal foreign bodies typically first present to the emergency department, with coins being most common in children and food boluses most common in adults. Controversy exists regarding the best treatment options in these cases. We report two cases, one pediatric and one adult, where the use of a novel substitute Hurst dilator constructed of materials regularly found in all EDs was successfully used to treat impacted esophageal foreign bodies.
       
  • You can dance if you want to: A case of Sydenham's chorea
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Ashley L. Lubberdink, Sameer Sharif, Kaif Pardhan Isolated motor disturbances in the paediatric population are uncommon presentations to the emergency department. Choreiform movements have a broad differential diagnosis and may present insidiously with progressive worsening of asymmetric clumsiness, hypotonia and dysarthria. The incidence of Sydenham's chorea (SC) caused by acute rheumatic fever (ARF) is very rare in developed countries. We report a previously healthy, vaccinated 9-year old male who presented to our ED with intermittent and progressive right sided clumsiness for four weeks. Physical examination findings showed dysdiadokinesis and dysmetric movements of the right side, which varied in intensity and were less pronounced on serial re-examination during the same ED visit. Basic bloodwork, MRI and MRA/V showed no abnormalities, and the patient was discharged home with urgent neurology follow-up. He re-presented to our ED four days later with worsening gait and inability to hold a pencil at school. He was subsequently diagnosed with chorea by the neurology team. The cause of chorea was later determined to be SC, and the patient's throat swab came back positive for group A-beta hemolytic strep (GAS) infection. We explore current literature regarding the various presentations of ARF, differential considerations in acute chorea, and diagnostic studies needed to determine the etiology of acute chorea. With the low incidence of chorea in developed nations, this diagnosis can be easily overlooked. We highlight the importance of this diagnosis, as well as primary and secondary treatment in ARF.
       
  • Molecular diagnostics, a strategy which does not address the diagnostic
           deficit in syphilitic meningitis
    • Abstract: Publication date: Available online 24 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Oscar M.P. Jolobe
       
  • Variations in access to specialty care for children with severe burns
    • Abstract: Publication date: Available online 21 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Clifton Ewbank, Clifford C. Sheckter, Nicholus M. Warstadt, Elizabeth A. Pirrotta, Catherine Curtin, Christopher Newton, N. Ewen Wang BackgroundPediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.MethodsUsing weighted discharge data from the Nationwide Inpatient Sample 2001–2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.ResultsOf 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p 
       
  • Protocol deviations in intravenous acetylcysteine therapy for
           acetaminophen toxicity
    • Abstract: Publication date: Available online 21 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Nadia I. Awad, Ann-Jeannette Geib, Akshay Roy, Craig Cocchio, Patrick J. Bridgeman
       
  • The utility of the speed bump sign for diagnosing acute appendicitis
    • Abstract: Publication date: Available online 20 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Mustafa Mahmood Eid, Maythem Al-Kaisy BackgroundAcute appendicitis is the most common abdominal complaint in the emergency department. This study was made in order to determine whether there is any evidence to support the practice of inquiring about pain over speed bumps in patient suspected to have acute appendicitis and to discover its predictive power as a diagnostic sign.MethodA prospective study was conducted in the emergency department of Al Ain Hospital over one year. A convenient sample of 100 consecutive adult patients over the age of 15 years who presented with an abdominal pain and symptoms suggestive of acute appendicitis were recruited over the study period. They all underwent questionnaire of whether they had pain, or their pain increased while they travelled over speed bumps.ResultsThe study shows that 80 of the 90 participants were “speed bump positive.” Eighty-five had a confirmed diagnosis of appendicitis, 77 of whom had worsened pain over speed bumps, giving a sensitivity of 90.5% and a specificity of 40%. The positive predictive value was 96.25% and the negative predictive value was 20%. The likelihood ratios were 1.5 for a positive test result and 0.23 for a negative result.ConclusionThe pain over speed bump can be considered as a significant “rule out” criterion of appendicitis due to the high sensitivity observed in this study. However, with its low specificity, many patients with this sign would not undoubtedly have appendicitis, meaning it is a poor “rule-in” test.
       
  • Evaluation and management of cauda equina syndrome in the emergency
           department
    • Abstract: Publication date: Available online 20 August 2019Source: The American Journal of Emergency MedicineAuthor(s): Brit Long, Alex Koyfman, Michael Gottlieb BackgroundCauda equina syndrome (CES) may be a devastating disease with the potential for significant patient morbidity. It is essential for emergency clinicians to be aware of how to effectively diagnose and manage this condition.ObjectiveThis article provides a narrative review of the diagnosis and management of CES for the emergency clinician.DiscussionCauda equina syndrome is a rare but emergent condition associated with back pain. It can result in severe morbidity and can be due to a variety of causes, most commonly vertebral disc protrusion. Diagnosis is often delayed, which may result in a poor prognosis. Red flags and findings consistent with CES include bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function leading to painless urinary retention, loss of anal tone, and loss of sexual function. In isolation, history and examination findings demonstrate poor sensitivity. Symptoms may occur either suddenly or gradually, and most patients do not present with all of these symptoms. Postvoid bladder volume assessments can assist in the evaluation, but the diagnosis typically involves magnetic resonance imaging (MRI) or computed tomography myelography if MRI is not available. Treatment relies upon surgical consultation and operative intervention for decompression.ConclusionCauda equina syndrome can be a difficult diagnosis. However, knowledge of the history and examination findings, imaging, and treatment can assist the emergency clinician in optimizing management of this condition.
       
 
 
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