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1.
Mauro Giordano Tiziana Ciarambino Emanuela Lo Priore Pietro Castellino Lorenzo Malatino Alessandro Cataliotti Giuseppe Paolisso Luigi Elio Adinolfi 《The American journal of emergency medicine》2017,35(11):1691-1694
Study objective
We investigated the serum sodium correction rate on length of hospitalization and survival rate, in severe chronic hyponatremic patients at the Emergency Department (ED).Design
An observational study using clinical chart review.Setting
The ED of the University Hospital of Marcianise, Caserta, Italy with approximately 30,000 patients visits a year.Type of participants
We reviewed sixty-seven patients with severe hyponatremia subdivided in 2 subgroups: group A consisting of 35 patients with serum sodium correction rate < 0.3 mmol/h and group B consisting of 32 patients with serum sodium correction rate between < 0.5 and ≥ 0.3 mmol/h.Intervention
Emergency patients were evaluated for serum sodium correction rate for hyponatremia by clinical chart review.Measurements and main results
Severe hyponatremia was defined as a serum sodium level < 120 mmol/l. Mean serum sodium correction rate of hyponatremia was of 0.17 ± 0.09% in group A and 0.41 ± 0.05% in group B (p < 0.001 vs group A). The length of hospital stay was 10.7 ± 3.7 days for group A, and it was significantly decreased to 3.8 ± 0.4 days for group B (p < 0.005 vs group A). In addition we observed that correction rate of hyponatremia in group A was associated with a significantly lower survival rate (25%) in comparison to group B (60%) (p < 0.001 vs group A).Conclusion: We observed that serum sodium correction rate ≥ 0.3 and < 0.5 mmol/h was associated with a shorter length of hospital stay and a major survival rate. 相似文献2.
Matthew J. Binks Rhys S. Holyoak Thomas M. Melhuish Ruan Vlok Elyse Bond Leigh D. White 《The American journal of emergency medicine》2017,35(10):1542-1546
Background
Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting.Aim
To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval.Methods
We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta-analysis of the pooled data.Results
Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004).Conclusion
Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first-pass success rate in this setting. 相似文献3.
Joshua J. Solano Nicole M. Dubosh Philip D. Anderson Richard E. Wolfe Jonathan A. Edlow Shamai A. Grossman 《The American journal of emergency medicine》2017,35(5):753-756
Background
Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging.Objective
To investigate the utility of tracking patients transferred to the ICU within 24 h of admission from the ED as a marker of preventable errors and adverse events.Methods
From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24 h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement.Results
Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24 h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%).Conclusion
Tracking patients admitted to the hospital from the ED who are transferred to the ICU < 24 h after admission may be a valuable marker for adverse events and preventable errors in the ED. 相似文献4.
Lucas Oliveira J. e Silva M. Fernanda Bellolio Elisa M. Smith David J. Daniels Christine M. Lohse Ronna L. Campbell 《The American journal of emergency medicine》2017,35(10):1485-1489
Background
Motor vehicle–related injuries (including off-road) are the leading cause of traumatic brain injury (TBI) and acute traumatic spinal cord injury in the United States.Objectives
To describe motocross-related head and spine injuries of adult patients presenting to an academic emergency department (ED).Methods
We performed an observational cohort study of adult ED patients evaluated for motocross-related injuries from 2010 through 2015. Electronic health records were reviewed and data extracted using a standardized review process.Results
A total of 145 motocross-related ED visits (143 unique patients) were included. Overall, 95.2% of patients were men with a median age of 25 years. Sixty-seven visits (46.2%) were associated with head or spine injuries. Forty-three visits (29.7%) were associated with head injuries, and 46 (31.7%) were associated with spine injuries. Among the 43 head injuries, 36 (83.7%) were concussions. Seven visits (16.3%) were associated with at least 1 head abnormality identified by computed tomography, including skull fracture (n = 2), subdural hematoma (n = 1), subarachnoid hemorrhage (n = 4), intraparenchymal hemorrhage (n = 3), and diffuse axonal injury (n = 3). Among the 46 spine injuries, 32 (69.6%) were acute spinal fractures. Seven patients (4.9%) had clinically significant and persistent neurologic injuries. One patient (0.7%) died, and 3 patients had severe TBIs.Conclusion
Adult patients evaluated in the ED after motocross trauma had high rates of head and spine injuries with considerable morbidity and mortality. Almost half had head or spine injuries (or both), with permanent impairment for nearly 5% and death for 0.7%. 相似文献5.
Michael D. Perloff Nimesh S. Patel Carlos S. Kase Anuja U. Oza Barbara Voetsch Jose R. Romero 《The American journal of emergency medicine》2017,35(11):1724-1729
Objective
To evaluate occurrence of cerebellar stroke in Emergency Department (ED) presentations of isolated dizziness (dizziness with a normal exam and negative neurological review of systems).Methods
A 5-year retrospective study of ED patients presenting with a chief complaint of “dizziness or vertigo”, without other symptoms or signs in narrative history or on exam to suggest a central nervous system lesion, and work-up included a brain MRI within 48 h. Patients with symptoms commonly peripheral in etiology (nystagmus, tinnitus, gait instability, etc.) were included in the study. Patient demographics, stroke risk factors, and gait assessments were recorded.Results
One hundred and thirty-six patients, who had a brain MRI for isolated dizziness, were included. There was a low correlation of gait assessment between ED physician and Neurologist (49 patients, Spearman's correlation r2 = 0.17). Based on MRI DWI sequence, 3.7% (5/136 patients) had acute cerebellar strokes, limited to or including, the medial posterior inferior cerebellar artery vascular territory. In the 5 cerebellar stroke patients, mean age, body mass index (BMI), hemoglobin A1c, gender distribution, and prevalence of hypertension were similar to the non-cerebellar stroke patient group. Mean LDL/HDL ratio was 3.63 ± 0.80 and smoking prevalence was 80% in the cerebellar stroke group compared to 2.43 ± 0.79 and 22% (respectively, p values < 0.01) in the non-cerebellar stroke group.Conclusions
Though there was preselection bias for stroke risk factors, our study suggests an important proportion of cerebellar stroke among ED patients with isolated dizziness, considering how common this complaint is. 相似文献6.
Rex Pui Kin Lam Wai Lam Yip Chi Keung Wan Matthew Sik Hon Tsui 《The American journal of emergency medicine》2017,35(4):665.e1-665.e4
Background
Chemical restraint is often required to control agitation induced by methamphetamine. Dexmedetomidine is an α-2 adrenergic receptor agonist with sedative, analgesic, and sympatholytic properties. Its use in the emergency department (ED) to control methamphetamine-induced agitation has not been reported.Objective
To report two cases of methamphetamine-induced agitation successfully sedated with dexmedetomidine in the ED.Case Report
The first case was a 42-year-old man with unstable emotion and violent behaviours after smoking methamphetamine. His agitation did not respond to a large cumulative dose of benzodiazepines (10 mg of diazepam and 332 mg of midazolam) administered over 48 h and sedation was achieved with dexmedetomidine. The second case was a 38-year-old methamphetamine user with unstable emotion and recurrent episodes of agitation despite repeated doses of benzodiazepines, whose agitation was controlled with dexmedetomidine infusion.Discussion
In both cases, dexmedetomidine apparently reduced the dose of benzodiazepines needed to achieve adequate sedation. Transient falls in blood pressure and slowing of the heart rate were noted, which resolved either spontaneously or after reducing the infusion rate without requiring drug treatment.Conclusion
Dexmedetomidine can be considered as an adjunct for chemical restraint when standard treatment fails to control the agitation induced by methamphetamine, but patient's hemodynamic state should be monitored closely during administration. Its efficacy and safety in the ED warrant further evaluation with prospective controlled trials. 相似文献7.
Peter Pruitt Joshua Penn David Peak Pierre Borczuk 《The American journal of emergency medicine》2017,35(2):255-259
Background
Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.Objective
Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).Methods
Retrospective evaluation of patients age ≥ 16, GCS ≥ 13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.Results
1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure > 2 weeks after discharge.Conclusions
Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit. 相似文献8.
Joseph B. Miller Richard M. Nowak Brian P. Reed Salvatore DiSomma Prabath Nanayakkara Michele Moyer Scott Millis Harish Kinni Phillip Levy 《The American journal of emergency medicine》2017,35(12):1915-1918
Background
Systemic hemodynamic characteristics of patients with suspected acute ischemic stroke are poorly described. The objective of this study was to identify baseline hemodynamic characteristics of emergency department (ED) patients with suspected acute stroke.Methods
This was a planned analysis of the stroke cohort from a multicenter registry of hemodynamic profiling of ED patients. The registry prospectively collected non-invasive hemodynamic measurements of patients with suspicion for acute stroke within 12 h of symptom onset. K-means cluster analysis identified hemodynamic phenotypes of all suspected stroke patients, and we performed univariate hemodynamic comparisons based on final diagnoses.Results
There were 72 patients with suspected acute stroke, of whom 38 (53%) had a final diagnosis of ischemic stroke, 10 (14%) had hemorrhagic stroke, and 24 (33%) had transient ischemic attack (TIA). Analysis defined three phenotypic clusters based on low or normal cardiac index (CI) and normal or high systemic vascular resistance index (SVRI). Patients with TIA had lower mean CI (2.3 L/min/m2) compared to hemorrhagic or ischemic stroke patients (p < 0.01).Conclusions
The study demonstrates the feasibility of defining hemodynamic phenotypes of ED patients with suspected stroke. 相似文献9.
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10.
Michael D. April Chase Donaldson Lloyd I. Tannenbaum Tyler Moore Jose Aguirre Alexander Pingree James H. Lantry 《The American journal of emergency medicine》2017,35(10):1474-1479
Background
Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L).Methods
We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012–28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patient's record including demographics, clinical data, treatments, and in-hospital mortality. We compared in-hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in-hospital mortality based on presence of refractory hypotension or hyperlactatemia.Results
Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in-hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5–3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2–7.4).Conclusions
Hyperlactatemia appears associated with higher in-hospital mortality compared to refractory hypotension among ED patients with septic shock. 相似文献11.
Christopher N. Kaufmann Adam P. Spira G. Caleb Alexander Lainie Rutkow Ramin Mojtabai 《The American journal of emergency medicine》2017,35(10):1414-1419
Objective
Sedative-hypnotic medications (e.g., Benzodiazepines [BZDs] and non-benzodiazepine receptor agonists [nBZRAs]) are associated with adverse events, especially in the elderly, that may require emergency department (ED) treatment. This study assessed outcomes from ED visits attributed to BZDs and/or nBZRAs, and variations in these associations by age group.Methods
Data came from the 2004–2011 waves of the Drug Abuse Warning Network (DAWN). Visits were categorized as involving: (1) BZDs-only, (2) nBZRAs-only, (3) combination of BZDs and nBZRAs, or (4) any other sedative-hypnotic medication. DAWN also recorded the disposition (i.e., outcome) of the visit. Analyses focused on outcomes indicating a serious disposition defined as hospitalization, patient transfer or death. Using logistic regression, the association of BZD and nBZRA use with visit disposition was assessed after applying sample weights so as to be nationally representative of ED visits in the United States involving medications or illicit substances.Results
Nineteen percent of visits involving other sedative-hypnotics, 28% involving BZDs-only, 20% involving nBZRAs-only and 48% involving a combination of BZDs and nBZRAs resulted in a serious disposition. Compared to visits involving other sedative-hypnotics, visits involving BZDs-only had 66% greater odds (Odds Ratio [OR] = 1.66, 95% Confidence Interval [CI] = 1.37–2.01), and visits involving a combination of BZDs and nBZRAs had almost four times increased odds of a serious disposition (OR = 3.91, 95% CI = 2.38–6.41). Results were similar across age groups.Conclusions
Findings highlight the need for clinical and regulatory initiatives to reduce BZD use, especially in combination with nBZRAs, and to promote treatment with safer alternatives to these medications. 相似文献12.
Tomer Begaz David Elashoff Tristan R. Grogan David Talan Breena R. Taira 《The American journal of emergency medicine》2017,35(10):1426-1429
Study objectives
To compare diagnostic test ordering practices of NPs with those of physicians in the role of Provider in Triage (PIT).Methods
This was a secondary analysis of data from a prospective RCT of waiting room diagnostic testing, where 770 patients had diagnostic studies ordered from the waiting room. The primary outcome was the number of test categories ordered by provider type. Other outcomes included total tests ordered by the end of ED stay, and time in an ED bed. We compared variables between groups using t-test and chi-square, constructed logistic regression models for individual test categories, and univariate and multivariate negative binomial models.Results
Physicians ordered significantly more diagnostic test categories than NPs (1.75 vs. 1.54, p < 0.001). By the end of their ED stay, there was no significant difference in total test categories ordered between provider type: physician 2.67 vs. NP 2.53 (p = 0.08), using a nonbinomial model, incidence rate ratio (IRR) 1.07 (0.98–1.17). Patient time in an ED bed was not significantly different between physicians and NPs (NP 244 min, SD = 133, Physicians 248 min, SD = 152) difference 4 min (? 24.3–16.1) p = 0.688.Conclusion
NPs in the PIT role ordered slightly less diagnostic tests than attending physicians. This slight difference did not affect time spent in an ED bed. By the end of the ED stay, there was no significant difference in total test categories ordered between provider types. PIT staffing with NPs does not appear to be associated with excess test ordering or prolonged ED patient stays. 相似文献13.
Sarah D. Meskill Paula A. Revell Lakshmi Chandramohan Andrea T. Cruz 《The American journal of emergency medicine》2017,35(3):495-498
Background
Respiratory syncytial virus (RSV) and influenza have varying degree of seasonal overlap.Objective
To determine the prevalence of co-infection of RSV and influenza compared to the prevalence of those infections independently when both are in season.Methods
This was a retrospective cross-sectional study of children evaluated between July 2010 and June 2013 for viral respiratory infection using multiplex PCR. Seasonality was defined retrospectively as weeks when > 2% of the total annual positive tests were obtained and was calculated for influenza A, influenza B, and RSV independently. Periods of overlapping seasonality of RSV and influenza A and RSV and influenza B were identified. The expected incidences of co-infection were modeled as the product of the incidences of the individual viruses.Results
13,664 specimens were sent for PCR during the study period. Over all 3 seasons, RSV overlapped with influenza A and B for 22 and 18 weeks, respectively; in 2011–12, RSV overlapped with neither influenza A nor B. Based on modeling, there were 6–7 fold fewer cases of RSV/influenza co-infection observed than expected: RSV/influenza A 77 vs. 12, (p ≤ 0.001; RSV/influenza B 76 vs. 11 (p ≤ 0.001).Conclusions
The observed incidence of co-infectivity of RSV and influenza was significantly less than the expected incidence even when both were co-circulating. In light of these data, it may be reasonable to forgo rapid influenza testing or empiric antiviral treatment for children whom rapid RSV testing is positive and who are at low risk of influenza-related complications, especially in times of antiviral therapy shortages. 相似文献14.
Samantha Dankoff Patricia Li Adam J. Shapiro Terry Varshney Alexander S. Dubrovsky 《The American journal of emergency medicine》2017,35(4):615-622
Objectives
Primary objective was to characterize lung ultrasound findings in children with asthma presenting with respiratory distress to the emergency department (ED). Secondary objectives included correlating these findings with patients' clinical course in the ED.Methods
Eligible patients 2–17 years of age, underwent a lung ultrasound by the study sonographer between November 2014 to December 2015. Positive lung ultrasound was defined as the presence of ≥ 1 of the following findings: ≥ 3 B-lines per intercostal space, consolidation and/or pleural abnormalities. The treating physician remained blinded to ultrasound findings; clinical course was extracted from the medical chart.Results
A total of sixty patients were enrolled in this study. Lung ultrasound was positive in 45% (27/60) of patients: B-line pattern in 38%, consolidation in 30% and pleural line abnormalities in 12%. A positive lung ultrasound correlated with increased utilization of antibiotics (26% vs 0%, p = 0.03), prolonged ED length of stay (30% vs. 9%, p = 0.04) and admission rate (30% vs 0%, p = 0.03). Inter-rater agreement between novice and expert sonographers was excellent with a kappa of 0.92 (95% CI: 0.84–1.00).Conclusions
This study characterized lung ultrasound findings in pediatric patients presenting with acute asthma exacerbations; nearly half of whom had a positive lung ultrasound. Positive lung ultrasounds were associated with increased ED and hospital resource utilization. Future prospective studies are needed to determine the utility and reliability of this tool in clinical practice. 相似文献15.
Samir Haydar Matthew Spanier Patricia Weems Samantha Wood Tania Strout 《The American journal of emergency medicine》2017,35(11):1730-1733
Objectives
The Quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score has been shown to accurately predict mortality in septic patients and is part of recently proposed diagnostic criteria for sepsis. We sought to ascertain the sensitive of the score in diagnosing sepsis, as well as the diagnostic timeliness of the score when compared to traditional systemic inflammatory response syndrome (SIRS) criteria in a population of emergency department (ED) patients treated in the ED, admitted, and subsequently discharged with a diagnosis of sepsis.Methods
Electronic health records of 200 patients who were treated for suspected sepsis in our ED and ultimately discharged from our hospital with a diagnosis of sepsis were randomly selected for review from a population of adult ED patients (N = 1880). Data extracted included the presence of SIRS criteria and the qSOFA score as well as time required to meet said criteria.Results
In this cohort, 94.5% met SIRS criteria while in the ED whereas only 58.3% met qSOFA. The mean time from arrival to SIRS documentation was 47.1 min (95% CI: 36.5–57.8) compared to 84.0 min (95% CI: 62.2–105.8) for qSOFA. The median ED “door” to positive SIRS criteria was 12 min and 29 min for qSOFA.Conclusions
Although qSOFA may be valuable in predicting sepsis-related mortality, it performed poorly as a screening tool for identifying sepsis in the ED. As the time to meet qSOFA criteria was significantly longer than for SIRS, relying on qSOFA alone may delay initiation of evidence-based interventions known to improve sepsis-related outcomes. 相似文献16.
Michael A. Downes James K. Balshaw Tracy M. Muscat Nicole Ritchie Geoffrey K. Isbister 《The American journal of emergency medicine》2017,35(5):764-768
Objectives
This was a before and after study which sought to assess the impact of opening an ED short stay unit (ESSU) on the ED performance of poisoned patients.Methods
Data was collected from two groups of adult patients presenting to an ED with a tertiary referral inpatient Toxicology unit from the 2009 and 2012 calendar years, to assess the impact of the ESSU. The toxicology unit clinical database and hospital electronic medical records were interrogated for demographic, clinical and hospital flow details of presentations. The primary outcome was ED length of stay (LOS). Other outcomes included proportion of patients remaining in ED for their admission, 28 day re-presentations and hospital LOS.Results
During 2009, 795 patients met inclusion criteria, and during 2012, 762. The median LOS in ED was reduced from 8.5 h (IQR: 4.7–14 h) to 2.7 h (IQR: 1.6–4.6; p < 0.0001). The proportion of patients remaining in ED for their entire hospital stay was reduced from 515/795 (65%) to 56/762 (7.3%) [Absolute difference: 57%; 95% CI: 53 to 62%; p < 0.0001]. Total hospital LOS increased from 14.5 h (IQR: 8.4–21.8 h) to 16.7 h (IQR: 11.5–23; p < 0.0001), but there was a decrease in re-presentations with self-poisoning within 28 days from 6.9% in 2009 to 4.5% in 2012 (p < 0.038). There was no difference between disposition destination or toxins causing exposure between the two groups.Conclusions
The ESSU led to a significant improvement in ED performance of poisoned patients. It also potentially assisted in reducing ED overcrowding. 相似文献17.
Rohit P. Shenoi Elizabeth A. Camp Daniel M. Rubalcava Andrea T. Cruz 《The American journal of emergency medicine》2017,35(12):1791-1797
Introduction
Blunt trauma is a leading cause of pediatric morbidity. We compared injuries, interventions and outcomes of acute pediatric blunt torso trauma based on intent.Methods
We analyzed de-identified data from a prospective, multi-center emergency department (ED)-based observational cohort of children under age eighteen. Injuries were classified based on intent (unintentional/inflicted). We compared demographic, physical and laboratory findings, ED disposition, hospitalization, need for surgery, 30-day mortality, and cause of death between groups using Chi-squared or Fisher's test for categorical variables, and Mann-Whitney test for non-normal continuous factors comparing median values and interquartile ranges (IQR).Results
There were 12,044 children who sustained blunt torso trauma: Inflicted = 720 (6%); Unintentional = 9563 (79.4%); Indeterminate = 148 (1.2%); Missing = 1613 (13.4%). Patients with unintentional torso injuries significantly differed from those with inflicted injuries in median age in years (IQR) [10 (5, 15) vs. 14 (8, 16); p-value < 0.001], race, presence of pelvic fractures, hospitalization and need for non-abdominal surgery. Mortality rates did not differ based on intent. Further adjustment using binary, logistic regression revealed that the risk of pelvic fractures in the inflicted group was 96% less than the unintentional group (OR: 0.04; 95%CI: 0.01–0.26; p-value = 0.001).Conclusions
Children who sustain acute blunt torso trauma due to unintentional causes have a significantly higher risk of pelvic fractures and are more likely to be hospitalized compared to those with inflicted injuries. 相似文献18.
Background
Paraphimosis is an acute urologic emergency requiring urgent manual reduction, frequently necessitating procedural sedation (PS) in the pediatric population. The present study sought to compare outcomes among pediatric patients undergoing paraphimosis reduction using a novel topical anesthetic (TA) technique versus PS.Methods
We performed a retrospective analysis of all patients < 18 years old, presenting to a tertiary pediatric ED requiring analgesia for paraphimosis reduction between October 2013 and September 2016. The primary outcome was reduction first attempt success; secondary outcomes included Emergency Department length of stay (ED LOS), adverse events and return visits. Dichotomous outcomes were analyzed by Chi-square testing and multivariate linear regression was used to compare continuous variables.Results
Forty-six patients were included; 35 underwent reduction using TA, 11 by PS. Patient age and duration of paraphimosis at ED presentation did not differ between groups. There was no difference in first attempt success between TA (32/35, 91.4%) and PS groups (9/11, 81.8%; p = 0.37). Mean ED LOS was 209 min shorter for TA patients (148 min vs. 357 min, p = 0.001) and remained significantly shorter after controlling for age and duration of paraphimosis (adjusted mean difference ?198 min, p = 0.003). There were no return visits or major adverse events in either group, however, among successful reduction attempts, PS patients more frequently experienced minor adverse events (7/9 vs. 0/32, p < 0.001).Conclusions
Paraphimosis reduction using TA was safe and effective. Compared to PS, TA was associated with a reduced ED LOS and fewer adverse events. TA could potentially allow more timely reduction with improved patient experience and resource utilization. 相似文献19.
Laurent Puy Chantal Lamy Sandrine Canaple Audrey Arnoux Nicolas Laine Ella Iacob Jean-Marc Constans Olivier Godefroy 《The American journal of emergency medicine》2017,35(5):716-719
Background and purpose
Following the reorganization of a University Medical Center onto a single campus, an Intensive Care Unit was created within the adult Emergency Department (ED ICU). We assessed the effects of these organizational changes on acute stroke management and the intravenous administration of recombinant tissue plasminogen activator (IV rtPA), as characterized by the thrombolysis rate, door-to-needle time (DNT) and outcome at 3 months.Methods
Between October 2013 and September 2015, we performed a retrospective, observational, single-center, comparative study of patients admitted for ischemic stroke and treated with IV rtPA during two 321-day periods (before and after the creation of the ED ICU). All patients with ischemic stroke were included. Multivariable logistic regression models were performed. The DNT was stratified according to a threshold of 60 min. A favorable long-term outcome was defined as a modified Rankin score ≤ 2 at 3 months.Results
A total of 1334 ischemic stroke patients were included. Among them, 101 patients received IV rtPA. The frequency of IV rtPA administration was 5.8% (39 out of 676) before the creation of the ED ICU, and 9.3% (62 out of 668) afterwards (odds ratio (OR) [95% confidence interval (CI)]: 1.67 [1.08–2.60]; p = 0.02). Additionally, the DNT was shorter (OR [95%CI]: 4.30 [1.17–20.90]; p = 0.04) and there was an improvement in the outcome (OR [95%CI] = 1.30 [1.01–2.10]; p = 0.045).Conclusion
Our results highlight the benefits of a separate ED ICU within conventional ED for acute stroke management, with a higher thrombolysis rate, reduced intrahospital delays and better safety. 相似文献20.
Daniel B. Gingold Rachelle Pierre-Mathieu Brandon Cole Andrew C. Miller Joneigh S. Khaldun 《The American journal of emergency medicine》2017,35(5):737-742