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Anthony Hackett Jonathan Stuart Nathan Blessing Nathan Borden 《The American journal of emergency medicine》2018,36(11):2135.e7-2135.e8
Background
Headaches and visual complaints are common conditions encountered in the emergency department. While a patient's age, risk factors, and comorbidities often aid in risk stratification and guide emergency department evaluation, atypical presentations of serious disease may still occur in young otherwise healthy patientsCase
In this vignette we discuss a case of ocular (choroidal) melanoma in a 21?year-old female patient who presented with recurrent photopsia and headaches.Discussion
Ocular melanoma is the most common non-skin melanoma and should be considered by the emergency physician for patients with visual deficits. Likely presentations and risk factors for ocular melanoma will be discussed as well as emergency department and specialty management. 相似文献3.
Brian E. Driver Lauren R. Klein Alexandra L. Schick Matthew E. Prekker Robert F. Reardon James R. Miner 《The American journal of emergency medicine》2018,36(2):193-196
Study objective
Adverse events, including aspiration, occur during Emergency Department (ED) intubation, but their contemporary incidence is not well described. We sought to estimate the rate of aspiration pneumonia potentially related to emergency intubation.Methods
We conducted a prospective observational study of adult patients who were endotracheally intubated in the ED. Using a standard definition, we determined the proportion of patients who developed aspiration pneumonia after intubation. Aspiration pneumonia was defined as any of the following in patients without a diagnosis of community acquired pneumonia, healthcare-associated pneumonia, or aspiration prior to intubation: pathogenic growth in sputum culture, unexplained hypoxemia, or radiographic evidence of pneumonia in the first 48 h after intubation. Baseline characteristics and intubation details were compared for those with and without aspiration pneumonia.Results
879 patients were enrolled over a 30-month period. Intubation was facilitated by video laryngoscopy (49%), direct laryngoscopy (45%), nasal intubation (4%), a intubating laryngeal mask airway (1%), and a surgical airway (0.1%). 85% were intubated on the first attempt, 12% on the second, 3% on the third or more attempts. 25% of patients experienced an oxygen saturation < 90% during the intubation. After excluding patients not eligible for the outcome assessment (those who died within 48 h without findings of pneumonia), 66/823 (8%) developed aspiration pneumonia potentially related to ED intubation. In comparing those with and without aspiration pneumonia, there were no differences between first intubation attempt parameters and the occurrence of aspiration pneumonia.Conclusion
Aspiration pneumonia occurred commonly in this cohort. Although we did not identify any intubation factors that differed between those with and without with aspiration pneumonia, these findings should remind emergency physicians that emergency endotracheal intubation remains a high-risk procedure, and all care should be taken to minimize the risk of peri-intubation complications. 相似文献4.
Joseph B. Miller Alexander Lee Julian P. Suszanski Madison Tustian Jessica Levely Corcoran Steven Moore Lauren Rodriguez Christopher A. Lewandowski 《The American journal of emergency medicine》2018,36(6):1018-1021
Introduction
Retrospective data indicates that dehydration in acute ischemic stroke patients may be common, even though these patients frequently have elevated blood pressure. We sought to evaluate clinical and laboratory measures of intravascular volume status compared to more objective measures using ultrasound measurements of the inferior vena cava (IVC).Methods
This was a prospective observation study of acute ischemic stroke patients in the emergency department. Patients with NIH stroke scale ≥4 within 12?h of symptom onset were included. A trained ultrasonographer performed bi-dimensional imaging of the IVC with passive respiration to determine the percent inspiratory collapse and maximum diameter. We defined low intravascular volume as >50% IVC collapse and a maximal diameter?<?2.1?cm. Analysis was limited to patients with confirmed ischemic stroke.Results
There were 42 patients, of whom 31 had confirmed acute ischemic stroke. The mean age was 65?±?15?years, 52% were female, and 71% were hypertensive. The median NIH stroke scale score was 7 (IQR 5–15). Based on IVC ultrasound, low intravascular volume was present in 63% (95% CI 44–80%) of patients. A higher proportion of hypertensive patients had low intrasvascular volume (72% vs. 33%). There was poor correlation between IVC assessment of intrasvascular volume and blinded clinician assessment or laboratory markers of dehydration.Conclusion
The majority of ED acute ischemic stroke patients in this sample were hypertensive and demonstrated low intravascular volume based on IVC ultrasound. 相似文献5.
Samuel Mullinax Christen E. Chalmers Jesse Brennan Gary M. Vilke Kimberly Nordstrom Michael P. Wilson 《The American journal of emergency medicine》2018,36(10):1779-1783
Background
Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.Methods
This prospective observational study enrolled a convenience sample of patients who answered “yes” to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated.Results
276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66–0.73).Conclusion
Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED. 相似文献6.
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Robyn McDannold Bentley J. Bobrow Vatsal Chikani Annemarie Silver Daniel W. Spaite Tyler Vadeboncoeur 《The American journal of emergency medicine》2018,36(9):1640-1644
Background
Clinical investigations have shown improved outcomes with primary compression cardiopulmonary resuscitation strategies. It is unclear whether this is a result of passive ventilation via chest compressions, a low requirement for any ventilation during the early aspect of resuscitation or avoidance of inadvertent over-ventilation.Objectives
To quantify whether chest compressions with guideline-compliant depth (>2?in) produce measurable and substantial ventilation volumes during emergency department resuscitation of out-of-hospital cardiac arrest.Methods
This was a prospective, convenience sampling of adult non-traumatic out-of-hospital cardiac arrest patients receiving on-going cardiopulmonary resuscitation in an academic emergency department from June 1, 2011 to July 30, 2013. Cardiopulmonary resuscitation quality files were analyzed using R-Series defibrillator/monitors (ZOLL Medical) and ventilation data were measured using a Non-Invasive Cardiac Output monitor (Philips/Respironics, Wallingford, CT).Results
cardiopulmonary resuscitation quality data were analyzed from 21 patients (17 males, median age 59). The median compression depth was 2.2?in (IQR?=?1.9, 2.5) and the median chest compression fraction was 88.4% (IQR?=?82.2, 94.1). We were able to discern 580 ventilations that occurred during compressions. The median passive tidal volume recorded during compressions was 7.5?ml (IQR 3.5, 12.6). While the highest volume recorded was 45.8?ml, 81% of the measured tidal volumes were <20?ml.Conclusion
Ventilation volume measurements during emergency department cardiopulmonary resuscitation after out-of-hospital cardiac arrest suggest that chest compressions alone, even those meeting current guideline recommendations for depth, do not provide physiologically significant tidal volumes. 相似文献8.
Objectives
To establish the relationship between the use of home non-invasive ventilation (NIV) and inhospital mortality in people admitted due to exacerbation of their respiratory disease.Methods
Retrospective cohort study with 191 cases of patients attended at the emergency department of the Reina Sofía General University Hospital in Murcia due to ARF of any cause and who required NIV as supportive treatment.Results
Mortality among patients using NIV as routine home treatment was 6.45%, compared to 20.1% among those who did not use it (P < .05).Conclusions
routine domiciliary treatment with NIV has been shown to be a protective factor against inpatient hospital mortality for patients who underwent NIV during their admission, through the emergency department, for acute respiratory failure or acute chronic disease, regardless of the triggering pathology. 相似文献9.
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Shadi Lahham Brent A. Becker Abdulatif Gari Steven Bunch Maili Alvarado Craig L. Anderson Eric Viquez Sophia C. Spann John C. Fox 《The American journal of emergency medicine》2018,36(6):962-966
Background
Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging.Objective
The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis.Methods
We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities.Results
A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%.Conclusion
Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population. 相似文献11.
Ömer Salt Polat Durukan S. Ozkan R. Saraymen A. Sen M.A. Yurci 《The American journal of emergency medicine》2017,35(10):1440-1443
Introduction
Gastrointestinal bleeding is a significant cause of morbidity and mortality worldwide. In addition, it constitutes an important part of health expenditures.In this study, we aimed to determine whether there is a relationship between plasma copeptin levels and the etiology, location and severity of gastrointestinal bleeding.Materials and methods
This study was performed prospectively in 104 consecutive patients who were admitted to an emergency department with complaints of bloody vomiting or bloody or black stool. To evaluate the level of biochemical parameters such as Full Blood Count (FBC), serum biochemistry, bleeding parameters and copeptin, blood samples were obtained at admission. For the copeptin levels, 2 more blood samples were obtained at the 12th and 24th hours after admission.The values obtained were compared using statistical methods.Results
In terms of the etiology of bleeding, the copeptin levels in the patients with peptic ulcer were higher than the levels in patients with other gastrointestinal bleeding. However, the difference was not statistically significant.There were no significant differences among all groups' 0th, 12th and 24th hour levels of copeptin.Discussion
We conclude that copeptin cannot be effectively used as a biochemical parameter in an emergency department to determine the etiology and location of gastrointestinal bleeding. It can, however, be used to make decisions on endoscopy and the hospitalization of patients with suspected gastrointestinal bleeding. 相似文献12.
John S. Garrett Colyn Berry Hao Wong Huanying Qin Jeffery A. Kline 《The American journal of emergency medicine》2018,36(9):1581-1584
Background
To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction.Methods
Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model.Results
In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17?min (95% CI 15–18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention.Conclusions
Initiation of a vertical split flow model was associated with improved ED efficiency. 相似文献13.
Erhan Er Şeref Kerem Çorbacıoğlu Sertaç Güler Şahin Aslan Meltem Seviner Gökhan Aksel Burak Bekgöz 《The American journal of emergency medicine》2017,35(1):82-86
Purpose
Aimed to analyze demographical data and injury characteristics of patients who were injured in the Syrian Civil War (SCW) and to define differences in injury characteristics between adult and pediatric patients.Methodology
Patients who were injured in the SCW and transferred to our emergency department were retrospectively analyzed in this study during the 15-month period between July 2013 and October 2014.Results
During the study period, 1591 patients who were the victims of the SCW and admitted to our emergency department due to war injury enrolled in the study. Of these patients, 285 were children (18%). The median of the injury severity score was 16 (interquartile range [IQR]: 9–25) in all patients. The most frequent mechanism of injury was blunt trauma (899 cases, 55%), and the most frequently-injured region of the body was the head (676 cases, 42.5%). Head injury rates among the children's group were higher than those of the adult group (P < .001). In contrast, injury rates for the abdomen and extremities in the children's group were lower than those in the adult group (P < .001, P < .001).Conclusion
The majority of patients were adults, and the most frequent mechanism of injury was blunt trauma. Similarly, the children were substantially affected by war. Although the injury severity score values and mortality rates of the child and adult groups were similar, it was determined that the number of head injuries was higher, but the number of abdomen and extremity injuries was lower in the children's group than in the adult group. 相似文献14.
Allison Tadros Melinda Sharon Nicholas Chill Shane Dragan Jeremy Rowell Shelley Hoffman 《The American journal of emergency medicine》2018,36(8):1455-1458
Background
Work-related injuries are commonly seen in the emergency department (ED). This study sought to analyze characteristics of ED patient visits that were billed under workers' compensation.Methods
This was a retrospective chart review of visits during 2015 that were billed under workers' compensation at an academic ED. The following variables were collected: age, gender, mechanism of injury/exposure, diagnoses, imaging performed, specialty consultation, operative requirement, follow-up specialty, and ED disposition.Results
In 2015, 377 patients presented to the ED for work-related injuries. The most common mechanism of injury was fall. Frequent diagnoses included lower extremity injuries and hand/finger injuries. The most common consulting service was orthopedics. Only five patients were referred to occupational medicine for follow up.Conclusion
Knowledge of the types of occupational injuries and subsequent care required may help guide both workers and employers how to best triage patients within the healthcare system. Alternative settings such as occupational medicine or primary care services may be appropriate for some patients. 相似文献15.
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Michael Gottlieb Brit Long Alex Koyfman 《The American journal of emergency medicine》2018,36(4):699-706
Background
Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage.Objective
With the new evidence concerning the evaluation and treatment of urolithiasis, this review summarizes current literature regarding the ED management of urolithiasis.Discussion
Urolithiasis occurs primarily through supersaturation of urine and commonly presents with flank pain, hematuria, and nausea/vomiting. History, examination, and assessment with several laboratory tests are cornerstones of evaluation. Urinalysis is not diagnostic, but it may be used in association with other assessments. Risk assessment tools and advanced imaging can assist with diagnosis. Computed tomography (CT) is often considered the gold standard. Newer low-dose CT imaging may reduce radiation. Recent studies support ultrasound as an alternate diagnostic modality, especially in pediatric and pregnant patients. Nonsteroidal anti-inflammatory drugs remain first-line therapy, with opioids or intravenous lidocaine reserved for refractory pain. Tamsulosin can increase passage in larger stones but has not demonstrated benefit in smaller stones. Nifedipine and intravenous fluids are not recommended to facilitate passage. Surgical intervention is based upon stone size, duration, and modifying factors. Patients who are discharged should be advised on dietary changes.Conclusion
Urolithiasis is a common disease increasing in prevalence with the potential for significant morbidity. Focused evaluation with history, examination, and testing is important in diagnosis and management. Understanding the clinical features, risk assessment tools, imaging options, and treatment options can assist emergency physicians in the management of urolithiasis. 相似文献18.
Frances M. Russell Jeffrey A. Kline Timothy Lahm 《The American journal of emergency medicine》2018,36(2):281-284
Background
Right ventricular (RV) dysfunction and pulmonary hypertension (PH) are commonly unrecognized in the emergency department (ED), but are associated with poor outcomes. Prior research has found a 30% prevalence of isolated RV dysfunction in ED patients after non-significant computed tomographic pulmonary angiography (CTPA). We aimed to prospectively define the prevalence of RV dysfunction and/or PH in short of breath ED patients, and assess outcomes.Methods
Prospective observational study of patients with a non-significant CTPA. Isolated RV dysfunction and/or PH was defined as normal left ventricular function plus RV dilation, moderate to severe tricuspid regurgitation or RV systolic pressure > 40 mm Hg on comprehensive echocardiography.Results
Of 83 patients, 20 (24%, 95% [confidence interval] CI: 16–34%) had isolated RV dysfunction and/or PH. These patients had 40% ED recidivism and 30% hospital readmission at 30-days. When compared to patients with normal echocardiographic function, they had significantly longer intensive care unit and hospital length of stays.Conclusions
In a prospective cohort of ED patients, we found a high prevalence of isolated RV dysfunction and/or PH after a non-significant CTPA. These patients had high rates of recidivism and hospital readmission. This data supports a continued need for ED based screening and specialty referral. 相似文献19.
Sarah DeWitt Summer A. Chavez Jack Perkins Brit Long Alex Koyfman 《The American journal of emergency medicine》2017,35(11):1755-1758
Background
Fever is one of the most common complaints in the emergency department (ED) and is more complex than generally appreciated. The broad differential diagnosis of fever includes numerous infectious and non-infectious etiologies. An essential skill in emergency medicine is recognizing the pitfalls in fever evaluation.Objective of review
This review provides an overview of the complaint of fever in the ED to assist the emergency physician with a structured approach to evaluation.Discussion
Fever can be due to infectious or non-infectious etiology and results from the body's natural response to a pyrogen. Adjunctive testing including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin has been evaluated in the literature, but these tests do not have the needed sensitivity and specificity to definitively rule in a bacterial cause of fever. Blood cultures should be obtained in septic shock or if the results will change clinical management. Fever may not be always present in true infection, especially in elderly and immunocompromised patients. Oral temperatures suffer from poor sensitivity to diagnose fever, and core temperatures should be utilized if concern for fever is present. Consideration of non-infectious causes of elevated temperature is needed based on the clinical situation.Conclusion
Any fever evaluation must rigorously maintain a broad differential to avoid pitfalls that can have patient care consequences. Fever is complex and due to a variety of etiologies. An understanding of the pathophysiology, causes, and assessment is important for emergency physicians. 相似文献20.
Chih-Chia Hsieh Ching-Chi Lee Hsiang-Chin Hsu Hsin-I Shih Chien-Hsin Lu Chih-Hao Lin 《The American journal of emergency medicine》2017,35(1):39-44