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1.
Hernan Polo Friz Valentina Pezzetti Annalisa Orenti Alessandro Caleffi Valeria Corno Chiara Crivellari Francesco Petri Melisa Polo Friz Veronica Punzi Daniela Teruzzi Luca Cavalieri d&#x;Oro Cristina Giannattasio Giuseppe Vighi Claudio Cimminiello Patrizia Boracchi 《The American journal of emergency medicine》2019,37(5):799-804
Introduction
The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE.Methods
All patients aged >65?years with normotensive APE, consecutively evaluated in the Emergency Department since 2010 through 2014 were included in this retrospective cohort study. Area under the curve (AUC) and ½ Net Reclassification Improvement (NRI) were calculated.Results
Study population: 162 patients, median age: 79.2?years. The optimal cut-off value of CCI score for predicting mortality was ≤1 (Low CB) and >1 (High CB), AUC?=?0.786.Higher levels of D-dimer were associated with an increased risk death at 30 (HR?=?1.039, 95%CI:1.000–1.080, p?=?0.049) and 90?days (HR?=?1.039, 95%CI:1.009–1.070, p?=?0.012). When added to simplified Pulmonary Embolism Severity Index (sPESI) score, D-dimer increased significantly the AUC for predicting 30-day mortality in Low CB (AUC?=?0.778, 95%CI:0.620–0.937, ½NRI?=?0.535, p?=?0.015), but not in High CB patients (AUC?=?0.634, 95%CI:0.460–0.807, ½ NRI?=?0.248, p?=?0.294). Similarly, for 90-day mortality D-dimer increased significantly the AUC in Low CB (AUC?=?0.786, 95%CI:0.643–0.929, ½NRI?=?0.424, p-value?=?0.025), but not in High CB patients (AUC?=?0.659, 95%CI:0.541–0.778, ½NRI?=?0.354, p-value?=?0.165).Conclusion
In elderly patients with normotensive APE, comorbidities condition the prognostic performance of D-dimer, which was found to be a better predictor of death in subjects with low CB. These results support multimarker strategies for risk assessment in this population. 相似文献2.
Mikio Nakajima Shotaro Aso Hideo Yasunaga Masamitsu Shirokawa Tomotsugu Nakano Yasuhiko Miyakuni Hideaki Goto Yoshihiro Yamaguchi 《The American journal of emergency medicine》2019,37(1):89-93
Background
Short-distance air medical transport for adult emergency patients does not significantly affect patients' body temperature and outcomes. This study aimed to examine the influence of long-distance air medical transport on patients' body temperatures and the relationship between body temperature change and mortality.Methods
We retrospectively enrolled consecutive patients transferred via helicopter or plane from isolated islands to an emergency medical center in Tokyo, Japan between April 2010 and December 2016. Patients' average body temperature was compared before and after air transport using a paired t-test, and corrections between body temperature change and flight duration were calculated using Pearson's correlation coefficient. Multivariable logistic regression models were then used to examine the association between body temperature change and in-hospital mortality.Results
Of 1253 patients, the median age was 72?years (interquartile range, 60–82?years) and median flight duration was 71?min (interquartile range, 54–93?min). In-hospital mortality was 8.5%, and average body temperature was significantly different before and after air transport (36.7?°C versus 36.3?°C; difference: ?0.36?°C; 95% confidence interval, ?0.30 to ?0.42; p?<?0.001). There was no correlation between body temperature change and flight duration (r?=?0.025, p?=?0.371). In-hospital death was significantly associated with (i) hyperthermia (>38.0?°C) or normothermia (36.0–37.9?°C) before air transport and hypothermia after air transport (odds ratio, 2.08; 95% confidence interval, 1.20–3.63; p?=?0.009), and (ii) winter season (odds ratio, 2.15; 95% confidence interval, 1.08–4.27; p?=?0.030).Conclusion
Physicians should consider body temperature change during long-distance air transport in patients with not only hypothermia but also normothermia or hyperthermia before air transport, especially in winter. 相似文献3.
Chenliang Sun Hongsheng Zhao Yang Lu Zhiwei Wang Wanjiang Xue Shu Lu Haoliang Shen Yiping Wang Qingyun Peng Lili Huang 《The American journal of emergency medicine》2019,37(2):254-259
Background
We evaluated factors associated with mortality in patients with moderate/severe generalized tetanus.Methods
This retrospective study included patients with moderate/severe generalized tetanus admitted to the Affiliated Hospital of Nantong University (China) between January 2005 and January 2017. Clinical data were extracted from medical records. Patients were divided into two groups based on outcome (survival or death). Factors associated with mortality were analyzed using univariate and multivariate logistic regression.Results
Seventy-five patients were included (57.3% male; age, 57.9?±?18.4?years; APACHE II score, 10.6?±?3.4; severe tetanus, 49.3%; mortality, 25.3%). Multivariate analysis identified severe tetanus (odds ratio [OR], 30.364; 95% confidence interval [CI], 2.459–374.896) and APACHE II score (OR, 1.536; 95%CI, 1.051–2.243) as positively associated with mortality, whereas high-calorie nutrition (OR, 0.027; 95%CI, 0.002–0.359) and dexmedetomidine use (OR, 0.035; 95%CI, 0.003–0.467) were negatively associated with mortality (all P?<?0.05).Conclusion
Tetanus severity and APACHE II score were associated with mortality in patients with generalized tetanus, whereas high-calorie nutrition and dexmedetomidine use reduced the odds of death. High-calorie nutrition and dexmedetomidine administration may improve prognosis in adult patients with moderate/severe generalized tetanus. 相似文献4.
David C. Mackenzie Aftab M. Azad Vicki E. Noble Andrew S. Liteplo 《The American journal of emergency medicine》2019,37(1):123-126
Objective
We sought to determine test performance characteristics of emergency physician ultrasound for the identification of gastric contents.Methods
Subjects were randomized to fast for at least 10?h or to consume food and water. A sonologist blinded to the patient's status performed an ultrasound of the stomach 10?min after randomization and oral intake, if applicable. The sonologist recorded their interpretation of the study using three sonographic windows. Subsequently 2 emergency physicians reviewed images of each study and provided an interpretation of the examination. Test performance characteristics and inter-rater agreement were calculated.Results
45 gastric ultrasounds were performed. The sonologist had excellent sensitivity (92%; 95% CI 73%–99%) and specificity (85%; 95% CI 62%–92%). Expert review demonstrated excellent sensitivity but lower specificity. Inter-rater agreement was very good (κ?=?0.64, 95%CI 0.5–0.78).Conclusion
Emergency physician sonologists were sensitive but less specific at detecting stomach contents using gastric ultrasound. 相似文献5.
Hiroyuki Inoue Shuji Uemura Keisuke Harada Hirotoshi Mizuno Naofumi Bunya Kazuhito Nomura Ryuichiro Kakizaki Eichi Narimatsu 《The American journal of emergency medicine》2019,37(2):189-193
Background
Pancreatic damage is commonly observed as a consequence of accidental hypothermia (core body temperature below 35?°C). We aimed to investigate the risk factors for pancreatic damage and the causal relationship in patients with accidental hypothermia.Methods
This retrospective, single-center, observational case-control study was conducted in the emergency department of a tertiary care medical center. We investigated patients who were admitted for accidental hypothermia over a course of ten years (January 2008 to December 2017).Results
Of the 138 enrolled patients, 70 had elevated serum amylase levels (51%). We observed a correlation between initial core body temperature and serum amylase level (Spearman's rank correlation coefficient ?0.302, p?<?0.001). Patients who developed acute pancreatitis had a significantly lower initial core body temperature than those who did not develop it (odds ratio?=?0.76; 95% confidence interval [CI]?=?0.61–0.94; p?=?0.011). Receiver operating characteristic analysis showed that a body temperature lower than 28.5?°C at the time of visit was predictive of acute pancreatitis (area under the curve?=?0.71, 95% CI?=?0.54–0.88, sensitivity?=?0.67, specificity?=?0.69, p?=?0.017).Conclusions
We concluded that an initial core body temperature lower than 28.5?°C was a risk factor for acute pancreatitis in accidental hypothermia cases. In such situations, careful follow-up is necessary. 相似文献6.
Jianfei Zheng Xudong Xiang Bing Xiao Huixia Li Xun Gong Shuo Yao Ting Yuan 《The American journal of emergency medicine》2018,36(3):480-487
Background
The potential benefits and possible risks associated with Xuebijing when combined with ulinastatin for sepsis treatment are not fully understood.Methods
Databases, such as PubMed, Web of Science, CNKI, WanFang and VIP, were searched to collect randomized, controlled trials. Studies were screened, data were extracted, and the methodological quality was assessed by two reviewers independently. A meta-analysis was carried out with Stata 11.0 software.Results
A total of 16 studies involving 1192 participants were enrolled for meta-analysis based on the inclusion and exclusion criteria. The results showed that compared with the group using routine therapies and the group using a single administration of either ulinastatin or Xuebijing, the trial group using Xuebijing combined with ulinastatin was significantly superior in the following aspects: mortality (RR?=?0. 54,95% CI (0. 41, 0. 70, P?=?.000), 7?d APACHE II (SMD?=??1.21, 95%CI (?1.62, ?0.80), P?=?.000), duration of mechanical ventilation (SMD?=??1.21, 95%CI (?1.62, ?0.80), P?=?.000), average length of time in the intensive care unit (SMD?=??1.21, 95%CI (?1.62, ?0.80), P?=?.000), incidence of multiple organ dysfunction syndromes (RR?=?0. 54, 95% CI (0.41, 0. 70, P?=?.000), interleukin-6 (SMD?=??1.36,95%CI (?2.46, ?0.27), P?=?.000), lipopolysaccharide (SMD?=??9.92, 95%CI (?11.7, ?7.90), P?=?.006), and procalcitonin (SMD?=??0.30, 95%CI (?0.34, ?0.26), P?=?.012).Conclusions
Our results found that Xuebijing when combined with ulinastatin was superior to both routine therapies and the single administration of either ulinastatin or Xuebijing. This finding provides a new therapeutic option for the treatment of sepsis. 相似文献7.
Background
Acute kidney injury (AKI) is a common complication in septic patients, imposing a heavy burden of illness in terms of morbidity and mortality. Serum lactate is a widely used marker predicting the severity of sepsis. A paucity of research has investigated septic AKI in emergency departments (EDs) and its correlation with initial serum lactate level. This study aimed at identifying risk factors for septic AKI and clarifying the link between initial serum lactate level and septic AKI in ED patients.Methods
A retrospective cohort study was conducted at a single tertiary referral medical center. The medical records of all adult ED patients with measurement of serum lactate and creatinine between January 2012 and December 2016 were reviewed. A total of 696 septic patients were stratified into AKI and non-AKI groups according to Acute Kidney Injury Network (AKIN) criteria for further statistical analysis.Results
Ninety-nine septic patients (14.2%) had AKI, with AKIN-I, AKIN-II, and AKIN-III in 71.7%, 11.1%, and 17.2% of patients, respectively. Compared with the non-AKI group, the AKI group had a significantly higher mortality rate (71.7% vs. 21.3%, p?<?0.001). Independent risk factors for septic AKI included liver disease (adjusted odds ratio [AOR]?=?2.02, 95% confidence interval [CI]?=?1.16–3.52), diabetes mellitus (AOR?=?1.73, 95% CI?=?1.11–2.69), chronic kidney disease (AOR?=?1.68, 95% CI?=?1.06–2.66), and initial serum lactate (AOR?=?1.08, 95% CI?=?1.02–1.14).Conclusions
Patients with septic AKI had an overwhelmingly higher mortality rate. The comorbidities of liver disease, diabetes mellitus, and chronic kidney disease were correlated with septic AKI and in combination with an elevated initial serum lactate level had predictive regarding AKI and further mortality in ED septic patients. 相似文献8.
9.
Namkyung Jeong Kyung Su Kim Yoon Sun Jung Taegyun Kim So Mi Shin 《The American journal of emergency medicine》2019,37(2):277-280
Objectives
To determine the association between delayed (>24?h) endoscopy and hospital mortality in patients with upper gastrointestinal hemorrhage (UGIH).Methods
We retrospectively analyzed all adult patients with UGIH who underwent endoscopy in a single emergency room for 2?years. The primary exposure was defined as >24?h from the ED visit to the first endoscopy. The primary outcome was defined as all cause hospital mortality. Secondary outcomes were intensive care unit admission rate, ED length of stay, and hospital length of stay.Results
Among 1101 patients enrolled, 898 received endoscopy within 24?h (early group) and 203 received endoscopy after 24?h (delayed group). The hospital mortality of early and delayed group was 2.8% and 6.4%, respectively (unadjusted relative risk [RR] 2.30: 95% CI, 1.20–4.42, p?=?0.012). This was significant after adjusting covariates including AIMS65 and Glasgow-Blatchford score (adjusted RR 2.23: 95% CI, 1.18–4.20, p?=?0.013). Intensive care unit admission rate was not different between two groups. ED and hospital length of stay were significantly longer in delayed group.Conclusions
Endoscopy performed after 24?h was associated with increased hospital mortality in UGIH. Patients in the delayed group stayed longer in the ED and in the hospital. 相似文献10.
R. Jouffroy A. Saade P. Alexandre P. Philippe P. Carli B. Vivien 《The American journal of emergency medicine》2019,37(3):387-390
Background
Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.Objective
We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30?min of advanced life support (ALS).Methodology
A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30?min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.Results
Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data.The mean value of cumulative dose of epinephrine was 10?±?4?mg in patients who failed to achieve ROSC (ROSC?) and 4?±?3?mg (p?=?0.04) for those who achieved ROSC.ROC curve analysis indicated a cut-off point of 7?mg total cumulative epinephrine associated with ROSC? (AUC?=?0.89 [0.86–0.92]).Using propensity score analysis including age, sex and no-flow duration, association with ROSC? only remained significant for epinephrine?>?7?mg (p?≤10–3, OR [CI95]?=?1.53 [1.42–1.65]).Conclusion
An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC? was reported with a threshold of 7?mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30?min of ALS. 相似文献11.
Atakan Yilmaz Ramazan Sabirli Mert Ozen Ibrahim Turkcuer Bulent Erdur Cuneyt Arikan Ezgi Demirozogul Ahmet Sarohan Murat Seyit Nusret Ok 《The American journal of emergency medicine》2019,37(5):902-908
Introduction
Musculoskeletal system traumas are among the most common presentations in the emergency departments. In the treatment of traumatic musculoskeletal pain, paracetamol and non-steroidal anti-inflammatory analgesics (NSAID) are frequently used. Our aim in this study is to compare the efficacy of intravenous dexketoprofen and paracetamol in the treatment of traumatic musculoskeletal pain.Methods
This prospective, randomised, double blind, controlled study was conducted in a tertiary care emergency unit. The participating patients were randomised into two groups to receive either 50?mg of dexketoprofen or 1000?mg of paracetamol intravenously by rapid infusion in 150?mL of normal saline. Visual analogue scale (VAS), Numeric Rating Scala (NRS) and Verbal Rating Scale (VRS) was employed for pain measurement at baseline, after 15, after 30 and after 60?mins.Results
200 patients were included in the final analysis. The median age of the paracetamol group was 34 (24–48), while that of the dexketoprofen group was 35 (23–50), and 63% (n?=?126) of them consisted of men. Paracetamol and dexketoprofen administration reduced VAS pain scores over time (p?=?0.0001). Median reduction in VAS score at 60?min was 55 (IQR 30–65) for the paracetamol group and 50(IQR 30.25–60) for the dexketoprofen group. There was no statistically significant difference between the paracetamol and dexketoprofen groups in terms of VAS reductions (p?=?0.613).Conclusion
Intravenous paracetamol and dexketoprofen seem to produce equivalent pain relief for acute musculoskeletal trauma in the emergency department.CLINICALTRIALS.GOV NO: NCT03428503 相似文献12.
Cody McIlvain Galadima Hadiza Theodore J. Tzavaras Gregory S. Weingart 《The American journal of emergency medicine》2019,37(3):472-477
Introduction
Hoverboards have become popular since they became available in 2015. We seek to provide an estimate of the number of injuries in the United States for 2015 and 2016, and to evaluate differences between adult and pediatric injury complexes.Methods
We performed a retrospective analysis of the National Electronic Injury Surveillance System (NEISS) from January 1, 2015 to December 31, 2016. Using the weighted design of the NEISS, a nationally representative sample could be determined.Results
During the 2?year period, there were 24,650 hoverboard related injuries (95% confidence interval [Cl], 17,635–31,664) in the US. The average age was 20.9?years old. There were 15,134 pediatric injuries (95%CI 9980–20,287) and 9515 adult injuries (95%CI 7185–11,845). Female patients compromised 51.2% of the sample. The upper extremity was the most common region injured [13,080 (95% CI 8848–17,311)] and fracture was the most common type of injury [10,074 (95% CI 6934–13,213)]. Hoverboard injuries increased from 2416 (95% CL 575–4245) in 2015 to 22,234 (95% CI 16,446–28,020) in 2016. Pediatric patients were more likely to be injured in the upper and lower extremity when compared to their adult cohort (p?=?0.0031). Six percent of the cohort [1575 (95% CI 665–2485)] sustained critical injuries with pediatric patients being at 1.46 times higher risk for life threatening injuries.Conclusion
Emergency department (ED) visits for hoverboard related injuries appear to be increasing. Pediatric patients are more at risk for hoverboard related injuries than adults and almost 6% of ED visits involved critical injuries, highlighting that hoverboards may be more dangerous than previously recognized. 相似文献13.
Sun Ju Kim Sumg Oh Hwang Yong Won Kim Jun Hyeok Lee Kyoung-Chul Cha 《The American journal of emergency medicine》2019,37(2):272-276
Introduction
The recent definition of sepsis was modified based on a scoring system focused on organ failure (Sepsis-3). It would be a time-consuming process to detect the sepsis patient using Sepsis-3. Procalcitonin (PCT) is a well-known biomarker for diagnosing sepsis/septic shock and monitoring the efficacy of treatment. We conducted a study to verify the predictability of PCT for diagnosing sepsis based on Sepsis-3 definition.Materials & methods
This is a retrospective cohort study. The patients whose PCT was measured on the emergency department (ED) arrival and had final diagnosis related infection were enrolled. The patients were categorized by infection, sepsis, or septic shock followed by Sepsis-3 definition. “Pre-septic shock” was defined when a patient was initially diagnosed with sepsis, following which his/her mean arterial blood pressure decreased to under 65?mmHg refractory to fluid resuscitation and there was need for vasopressor use during ED admission. Receiver operating characteristics (ROC) curve and area under the curve (AUC) analysis were performed to verify sensitivity and specificity of PCT.Results
866 patients were enrolled in the final analysis. There are 287 cases of infection, 470 cases of sepsis, and 109 cases of septic shock. An optimal cutoff value for diagnosing sepsis was 0.41?ng/dL (sensitivity: 74.8% and specificity: 63.8%; AUC: 0745), septic shock was 4.7?ng/dL (sensitivity: 66.1% and specificity: 79.0%; AUC: 0.784), and “pre-septic shock” was 2.48?ng/dL (sensitivity: 72.8%, specificity: 72.8%, AUC: 0.781), respectively.Conclusion
PCT is a reliable biomarker to predict sepsis or septic shock according to the Sepsis-3 definitions. 相似文献14.
Vincent J. Cascone Rose S. Cohen Nicholas P. Dodson Chad M. Cannon 《The American journal of emergency medicine》2019,37(5):947-951
Background
Previous research has illustrated the importance of collection of microbiologic cultures prior to first antimicrobial dose (FAD) in septic patients to avoid sterilization of pathogens and thus allowing confirmation of infection, identification of pathogen(s), and de-escalation of antimicrobial therapy. There is currently a lack of literature characterizing the implications and clinical courses of patients who have cultures collected after FAD.Methods
In this single-center, retrospective chart review of 163 sepsis cases in the emergency department, the primary outcome was positive-cultures from appropriate sources. Secondary outcomes included time to FAD (TFAD); ICU and hospital lengths of stay (LOS); rate of antibiotic restart; secondary infection rate; readmission; and mortality. Cases were divided based on culture timing relative to FAD: culture-first (CF) or antimicrobial-first (AF) cohorts.Results
Cultures were more frequently positive in the CF cohort vs. AF cohort overall (80.4% vs. 46.7%, p?<?0.005). TFAD was greater in the CF cohort (202?min vs. 153?min, p?=?0.036) and these cases trended toward shorter ICU and hospital LOS (6.8?days vs. 8.4?days, p?=?0.122; 11.5?days vs. 13.5?days, p?=?0.218). Antibiotic restart was less frequent in the CF cohort (10.7% vs. 17.8%, p?<?0.005). C. difficile infection and mortality trended toward lower incidence in the CF cohort, and readmission rates were similar.Conclusions
Sepsis patients who have cultures obtained after FAD (represented in the AF cohort) had less positive-cultures, shorter TFAD, a trend toward longer ICU and hospital LOS, and perhaps higher risk of C. difficile infection, and mortality. 相似文献15.
Leigh White Thomas Melhuish Rhys Holyoak Thomas Ryan Hannah Kempton Ruan Vlok 《The American journal of emergency medicine》2018,36(12):2298-2306
Objectives
To assess the difference in survival and neurological outcomes between endotracheal tube (ETT) intubation and supraglottic airway (SGA) devices used during out-of-hospital cardiac arrest (OHCA).Methods
A systematic search of five databases was performed by two independent reviewers until September 2018. Included studies reported on (1) OHCA or cardiopulmonary resuscitation, and (2) endotracheal intubation versus supraglottic airway device intubation. Exclusion criteria (1) stimulation studies, (2) selectively included/excluded patients, (3) in-hospital cardiac arrest. Odds Ratios (OR) with random effect modelling was used. Primary outcomes: (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, (4) discharge with a neurologically intact state.Results
Twenty-nine studies (n?=?539,146) showed that overall, ETT use resulted in a heterogeneous, but significant increase in ROSC (OR?=?1.44; 95%CI?=?1.27 to 1.63; I2?=?91%; p?<?0.00001) and survival to admission (OR?=?1.36; 95%CI?=?1.12 to 1.66; I2?=?91%; p?=?0.002). There was no significant difference in survival to discharge or neurological outcome (p?>?0.0125). On sensitivity analysis of RCTs, there was no significant difference in ROSC, survival to admission, survival to discharge or neurological outcome (p?>?0.0125). On analysis of automated chest compression, without heterogeneity, ETT provided a significant increase in ROSC (OR?=?1.55; 95%CI?=?1.20 to 2.00; I2?=?0%; p?=?0.0009) and survival to admission (OR?=?2.16; 95%CI?=?1.54 to 3.02; I2?=?0%; p?<?0.00001).Conclusions
The overall heterogeneous benefit in survival with ETT was not replicated in the low risk RCTs, with no significant difference in survival or neurological outcome. In the presence of automated chest compressions, ETT intubation may result in survival benefits. 相似文献16.
Brian W. Gilbert Joel B. Huffman Joe Slechta Christine Porter John M. Gallagher 《The American journal of emergency medicine》2019,37(2):294-297
Objective
The objective of this study was to evaluate a new multidisciplinary process in which intravenous alteplase (tPA) waste, used for acute ischemic stroke (AIS), was salvaged in an attempt to maximize cost effectiveness without impacting door-to-needle (DTN) administration times.Design
This was a retrospective cohort between May 2017 and February 2018. The primary endpoint evaluated for this study was the total tPA salvaged and total cost savings in U.S. dollars. Secondary endpoints evaluated included overall DTN time in minutes.Setting
Emergency department of a primary stroke center.Patients
A convenience sample of sequential adult (>18?years) patients who received tPA in the ED for AIS were included for analysis.Interventions
New stroke process which involved bedside mixing of tPA and salvaging of excess waste in the main central pharmacy.Measurements and main results
A total of 50 patients were included in the final analysis. There were 25 patients included in the new process and old process groups respectively. A total of 605?mg of alteplase was salvaged from 25 patients in the new process group which was associated with an estimated cost savings of over $120,000 annually. Patients in the new process group had statistically faster average (52?min vs. 60?min; p?=?0.01) and median (50?min vs. 58?min; p?=?0.03) DTN administration times.Conclusion
Preliminary data, in this pilot study, utilizing a multidisciplinary model for tPA administration led to significant cost savings of tPA and decreases in overall DTN administration times. 相似文献17.
Lynn Jiang Nicholas D. Caputo Bernard P. Chang 《The American journal of emergency medicine》2019,37(3):506-509
Objective
Early identification of shock allows for timely resuscitation. Previous studies note the utility of bedside calculations such as the shock index (SI) and quick sepsis-related organ failure assessment (qSOFA) to detect occult shock. Respiratory rate may also be an important marker of occult shock. The goal of our study was to evaluate whether using a modified SI with respiratory rate would improve identification of emergency department sepsis patients admitted to an ICU or stepdown unit.Methods
A prospective, observational cohort study of the respiratory adjusted shock index (RASI), defined as HR/SBP?×?RR/10, was conducted. RASI was calculated from triage vital signs and compared to serum lactate. Primary outcome was admission to a higher level of care defined as ICU or stepdown unit. A multivariable logistic regression model including RASI, SI, lactate, age and sex was performed with disposition as the outcome variable. Areas under the curve (AUC) were calculated to detect occult shock and level of care for RASI, SI, and qSOFA.Results
408 patients were enrolled, 360 were included in the analysis. Regression analysis revealed that lactate (OR 1.55, z?=?4.38, p?<?0.0001) and RASI (OR 2.27, z?=?3.03, p?<?0.002) were predictive of need for higher level of care. The AUC for RASI, SI, and qSOFA to detect occult shock were 0.71, 0.6, and 0.61 respectively. RASI also had a significant AUC in predicting level of care at 0.75 compared to SI (0.64) and qSOFA (0.62).Conclusions
RASI may have utility as a rapid bedside tool for predicting critical illness in sepsis patients. 相似文献18.
Richard B. Chow Andre Lee Bryan G. Kane Jeanne L. Jacoby Robert D. Barraco Stephen W. Dusza Matthew C. Meyers Marna Rayl Greenberg 《The American journal of emergency medicine》2019,37(3):457-460
Objective
We sought to evaluate the effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools in the Emergency Department (ED), stratified by sex.Methods
This prospective cohort study was conducted at a Level 1 Trauma center. After consent, subjects performed the TUG and the Chair test. Subjects were contacted for phone follow-up and asked to self-report interim falling.Results
Data from 192 subjects were analyzed. At baseline, 71.4% (n?=?137) screened positive for increased falls risk based on the TUG evaluation, and 77.1% (n?=?148) scored below average on the Chair test. There were no differences by patient sex.By the six-month evaluation 51 (26.6%) study participants reported at least one fall. Females reported a non-significant higher prevalence of falls compared to males (29.7% versus 22.2%, p?=?0.24). TUG test had a sensitivity of 70.6% (95% CI: 56.2%–82.5%), a specificity of 28.4% (95% CI: 21.1%–36.6%), a positive predictive (PP) value 26.3% (95% CI: 19.1%–34.5%) and a negative predictive (NP) value of 72.7% (95% CI: 59.0%–83.9%). Similar results were observed with the Chair test. It had a sensitivity of 78.4% (95% CI: 64.7%–88.7%), a specificity of 23.4% (95% CI: 16.7%–31.3%), a PP value 27.0% (95% CI: 20.1%–34.9%) and a NP value of 75.0% (95% CI: 59.7%–86.8%). No significant differences were observed between sexes.Conclusions
There were no sex specific significant differences in TUG or Chair test screening performance. Neither test performed well as a screening tool for future falls in the elderly in the ED setting. 相似文献19.
Romain Jouffroy Anastasia Saade Laure Castres Saint Martin Pascal Philippe Pierre Carli Benoit Vivien 《The American journal of emergency medicine》2019,37(1):56-60
Objective
Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation.Methods
We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28).Results
Forty-nine (64%) patients were included. The mean PaO2 at ICU admission was 153?±?77 and 202?±?82?mm?Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2?<?100, 25% for 100?<?PaO2?<?150 and 57% for a PaO2?>?150?mm?Hg. PaO2 was significantly associated with mortality at D28 (p?=?0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2?>?150?mm?Hg (p?=?0.02, OR [CI95]?=?1.59 [1.20–2.10]).Conclusions
In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation. 相似文献20.
Robert J. McLoughlin Jonathan Green Pradeep P. Nazarey Michael P. Hirsh Muriel Cleary Jeremy T. Aidlen 《The American journal of emergency medicine》2019,37(3):439-443