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Tamer N. Mansour Megan Rudolph Derek Brown Natalie Mansour M. Reza Taheri 《The American journal of emergency medicine》2017,35(1):112-116
Objective
The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos.Methods
In this retrospective institutional review board–approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair.Results
Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93.Conclusion
Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes. 相似文献2.
Troy Madsen Cameron Smyres Talmage Wood Tamara Moores Matthew Fuller Virgil Davis Kurt Bernhisel 《The American journal of emergency medicine》2017,35(1):25-28
Background
In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model).Methods
We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models.Results
Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up.Conclusion
An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model. 相似文献3.
Adam C. Patterson Shernaz A. Wadia Douglas J. Lorenz Michelle D. Stevenson 《The American journal of emergency medicine》2017,35(2):322-325
Background
Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children.Methods
We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight.Results
Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P < .001), DBP (P < .01), and HR (P < .001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P = .006) and DBP (P < .01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P < .001), mean DBP by 7 mm Hg (P < .001), and mean HR by 1 beat/min (P = .35).Conclusions
Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP. 相似文献4.
Robert F. Riley Chadwick D. Miller Gregory B. Russell Erin N. Harper Brian C. Hiestand James W. Hoekstra Cedric W. Lefebvre Bret A. Nicks David M. Cline Kim L. Askew Simon A. Mahler 《The American journal of emergency medicine》2017,35(1):77-81
Introduction
The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported.Methods and Results
We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period.Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group.Conclusions
Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings. 相似文献5.
John B. Harringa Rebecca L. Bracken Scott K. Nagle Mark L. Schiebler Brian W. Patterson James E. Svenson Michael D. Repplinger 《The American journal of emergency medicine》2017,35(1):146-149
Objective
Our aim was to validate the previously published claim of a positive relationship between low blood hemoglobin level (anemia) and pulmonary embolism (PE).Methods
This was a retrospective study of patients undergoing cross-sectional imaging to evaluate for PE at an academic medical center. Patients were identified using billing records for charges attributed to either magnetic resonance angiography or computed tomography angiography of the chest from 2008 to 2013. The main outcome measure was mean hemoglobin levels among those with and without PE. Our reference standard for PE status included index imaging results and a 6-month clinical follow-up for the presence of interval venous thromboembolism, conducted via review of the electronic medical record. Secondarily, we performed a subgroup analysis of only those patients who were seen in the emergency department. Finally, we again compared mean hemoglobin levels when limiting our control population to an age- and sex-matched cohort of the included cases.Results
There were 1294 potentially eligible patients identified, of whom 121 were excluded. Of the remaining 1173 patients, 921 had hemoglobin levels analyzed within 24 hours of their index scan and thus were included in the main analysis. Of those 921 patients, 107 (11.6%; 107/921) were positive for PE. We found no significant difference in mean hemoglobin level between those with and without PE regardless of the control group used (12.4 ± 2.1 g/dL and 12.3 ± 2.0 g/dL [P = .85], respectively).Conclusions
Our data demonstrated no relationship between anemia and PE. 相似文献6.
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Melissa K. James Sebastian D. Schubl Michael P. Francois Geoffrey K. Doughlin Shi-Wen Lee 《The American journal of emergency medicine》2017,35(1):13-19
Study Objective
The aim of this study is to determine if the introduction of a pan-scan protocol during the initial assessment for blunt trauma activations would affect missed injuries, incidental findings, treatment times, radiation exposure, and cost.Methods
A 6-month prospective study was performed on patients with blunt trauma at a level 1 trauma center. During the last 3 months of the study, a pan-scan protocol was introduced to the trauma assessment. Categorical data were analyzed by Fisher exact test and continuous data were analyzed by Mann-Whitney nonparametric test.Results
There were a total of 220 patients in the pre–pan-scan period and 206 patients during the pan-scan period. There was no significant difference in injury severity or mortality between the groups. Introduction of the pan-scan protocol substantially reduced the incidence of missed injuries from 3.2% to 0.5%, the length of stay in the emergency department by 68.2 minutes (95% confidence interval [CI], ?134.4 to ?2.1), and the mean time to the first operating room visit by 1465 minutes (95% CI, ?2519 to ?411). In contrast, fixed computed tomographic scan cost increased by $48.1 (95% CI, 32-64.1) per patient; however, total radiology cost per patient decreased by $50 (95% CI, ?271.1 to 171.4). In addition, the rate of incidental findings increased by 14.4% and the average radiation exposure per patient was 8.2 mSv (95% CI, 5.0-11.3) greater during the pan-scan period.Conclusion
Although there are advantages to whole-body computed tomography, elucidation of the appropriate blunt trauma patient population is warranted when implementing a pan-scan protocol. 相似文献9.
Maryann Mazer-Amirshahi Ali Pourmand Larissa May 《The American journal of emergency medicine》2017,35(1):154-158
Millions of patients are evaluated every year in the emergency department (ED) for bacterial infections. Emergency physicians often diagnose and prescribe initial antibiotic therapy for a variety of bacterial infections, ranging from simple urinary tract infections to severe sepsis. In life-threatening infections, inappropriate choice of initial antibiotic has been shown to increase morbidity and mortality. As such, initiation of appropriate antibiotic therapy on the part of the emergency physician is critical. Increasing rates of antibiotic resistance, drug allergies, and antibiotic shortages further complicates the choice of antibiotics. Patients may have a history of prior resistant infections or culture data indicating that common first-line antibiotics used in the ED may be ineffective. In recent years, there have been several new antibiotic approvals as well as renewed interest in second and third line antibiotics because of the aforementioned concerns. In addition, several newly approved antibiotics have the advantage of being administered once weekly or even as a single infusion, which has the potential to decrease hospitalizations and healthcare costs. This article reviews newly approved antibiotics and antibiotics used to treat resistant infections with a focus on implications for emergency medicine. 相似文献
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David M. Nestler Waqas I. Gilani Ryan T. Anderson M. Fernanda Bellolio Megan E. Branda Annie LeBlanc Sean Phelan Ronna L. Campbell Erik P. Hess 《The American journal of emergency medicine》2017,35(1):29-35
Objectives
Despite a high prevalence of coronary heart disease in both genders, studies show a gender disparity in evaluation whereby women are less likely than men to undergo timely or comprehensive cardiac investigation. Using videographic analysis, we sought to quantify gender differences in provider recommendations and patient evaluations.Methods
We analyzed video recordings from our Chest Pain Choice trial, a single center patient-level randomized trial in which emergency department patients with chest pain being considered for cardiac stress testing were randomized to shared decision-making or usual care. Patient-provider interactions were video recorded. We compared characteristics and outcomes by gender.Results
Of the 204 patients enrolled (101 decision aid; 103 usual care), 120 (58.8%) were female. Of the 75 providers evaluated, 20 (26.7%) were female. The mean (SD) pretest probability of acute coronary syndrome was lower in women [3.7% (2.2) vs 6.7% (4.4), P = .0002]. There was no gender effect on duration of discussion, clinician recommendations, OPTION scores, patient perceptions, or eventual patient dispositions. When the clinician and patient gender matched, OPTION scores were lower (interaction P = .002), and patients were less likely to find the information to be very helpful (interaction P = .10).Conclusions
Despite a lower pretest probability of acute coronary syndrome in women, we did not observe any significant gender disparity in how patients were managed and evaluated. When the patients' and providers' gender matched, the provider involved them less in the decision making process, and the information provided was less helpful than when the genders did not match. 相似文献14.
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Lauren T. Southerland Lauren Slattery Joseph A. Rosenthal Deborah Kegelmeyer Anne Kloos 《The American journal of emergency medicine》2017,35(2):329-332
Objectives
The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls.Methods
Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered.Results
The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n = 23) as at risk for falls, whereas the 4SBT identified 43% (n = 25). Combining triage questions with the 4SBT identified 60.3% (n = 35) as at high risk for falls, as compared with 39.7% (n = 23) with triage questions alone (P < .01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses).Conclusions
Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls. 相似文献18.
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