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1.
Christopher L. Hunter Salvatore Silvestri Amanda Stone Anne Shaughnessy Stacie Miller Alexa Rodriguez Linda Papa 《The American journal of emergency medicine》2019,37(1):114-117
Objective
To determine if prehospital identification of sepsis will affect time to Centers for Medicare and Medicaid services (CMS) sepsis core measures and improve clinical outcomes.Methods
We conducted a retrospective cohort study among septic patients who were identified as “sepsis alerts” in the emergency department (ED). Metrics including time from ED registration to fluid resuscitation, blood cultures, serum lactate draws, and antibiotics administration were compared between those who had pre-arrival notification by EMS versus those that did not. Additionally, outcomes such as mortality and intensive care unit (ICU) admission were recorded.Results
Of the 272 total patients, 162 had pre-arrival notification (prehospital sepsis alerts) and 110 did not. The prehospital sepsis alert group had significantly lower times to intravenous fluid administration (6?min 95%CI 4–9?min vs 41?min 95%CI 24–58?min, p?<?0.001), blood cultures drawn (12?min 95%CI 10–14?min vs 34?min 95%CI 20–48?min, p?=?0.003), lactate levels drawn (12?min 95%CI 10–15?min vs 34?min 95%CI 20–49?min, p?=?0.003), and administration of antibiotics (33?min 95%CI 26–40?min vs 61?min 95%CI 44–78?min, p?=?0.004). Patients with prehospital sepsis alerts also had a higher admission rate (100% vs 95%, p?=?0.006), and a lower ICU admission rate (33% vs 52%, p?=?0.003). There was no difference in mortality (11% vs 14%, p?=?0.565) between groups.Conclusions
Prehospital sepsis alert notification may decrease time to specific metrics shown to improve outcomes in sepsis. 相似文献2.
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3.
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4.
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5.
Brian J. Yun Robert M. Rodriguez Anand M. Prabhakar David A. Peak DaMarcus E. Baymon Ali S. Raja 《The American journal of emergency medicine》2019,37(5):909-912
Introduction
Increased use of computed tomography (CT) during injury-related Emergency Department (ED) visits has been reported, despite increased awareness of CT radiation exposure risks. We investigated national trends in the use of chest CT during injury-related ED visits between 2012 and 2015.Methods
Analyzing injury-related ED visits from the 2012–2015 United States (U.S.) National Hospital Ambulatory Medical Care Survey (NHAMCS), we determined the percentage of visits that had a chest CT and the diagnostic yield of these chest CTs for clinically-significant findings. We used survey-weighted multivariable logistic regression to determine which patient and visit characteristics were associated with chest CT use.Results
Injury-related visits accounted for 30% of the 135 million yearly ED visits represented in NHAMCS. Of these visits, 817,480 (2%) received a chest CT over the study period. The diagnostic yield was 3.88%. Chest CT utilization did not change significantly from a rate of 1.73% in 2012 to a rate of 2.31% in 2015 (p?=?0.14). Multivariate logistic regression demonstrated increased odds of chest CT for patients seen by residents versus by attendings (adjusted odds ratio [AOR] 2.08, 95% confidence interval [CI] 1.41–3.08). Patients aged 18–59 and 60+ had higher AORs (5.75, CI 3.44–9.61 and 9.81, CI 5.90–16.33, respectively) than those <18?years of receiving chest CT.Conclusions
Overall chest CT utilization showed an increased trend from 2012 to 2015, but the results were not statistically significant. 相似文献6.
Daisuke Katagiri Kent Doi Takehiro Matsubara Kousuke Negishi Yoshifumi Hamasaki Kensuke Nakamura Takeshi Ishii Naoki Yahagi Eisei Noiri 《Journal of critical care》2013
Purpose
Septic acute kidney injury (AKI) shows an unacceptably high mortality rate. Detection of sepsis is important for the clinical management of AKI patients. This study was undertaken to evaluate 2 biomarkers of neutrophil gelatinase–associated lipocalin (NGAL) and endotoxin activity (EA) assay and their combination for detecting sepsis in AKI.Materials and Methods
Adult intensive care unit patients consisting of 40 non-AKI, 65 AKI without sepsis, 10 non-AKI with sepsis, and 24 septic AKI were examined in a cross-sectional manner. Plasma NGAL and EA values in whole blood were measured at recruitment. We evaluated whether combining 2 different biomarkers would improve the performance of each biomarker using receiver operating characteristic analysis.Results
Plasma NGAL was significantly higher in septic AKI patients than in the other AKI patients and non-AKI patients, whereas EA values were higher in septic patients than nonseptic patients irrespective of AKI complication. Combination of plasma NGAL and EA value increased the area under the curve of the receiver operating characteristic curve and showed better performance compared with a clinical model consisting of clinically available variables.Conclusion
Combinations of plasma NGAL and EA, which are operating via different pathological pathways, significantly improved their detection performance in complicated conditions of septic AKI. 相似文献7.
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8.
Introduction
Dysnatremia is one of the most commonly encountered electrolyte disorders in the emergency department (ED). Few studies have reported the prevalence of dysnatremia in elderly patients without chronic kidney disease (CKD). We investigated the prevalence of dysnatremia in elderly patients without CKD in an emergency department in Japan.Methods
We reviewed 10,558 patients presenting to the ED between July 2015 and December 2017. The adult group consisted of 4562 patients aged between 18 and 64?years old, and the elderly group consisted of 5996 patients aged over 65?years. Information collected included age, gender, serum sodium and serum creatinine. Hyponatremia was defined as serum sodium level?<?135?mEq/L, and severe hyponatremia was defined as a serum sodium level?<?125?mEq/L. Hypernatremia was defined as a serum sodium level?>?145?mEq/L, and moderate to severe hypernatremia was defined as a serum sodium level?≧?150?mEq/L.Results
In the adult group, the prevalence of hyponatremia was 2.8% in patients without CKD and 10.3% in patients with CKD (P?<?0.001). On the other hand, in the elderly group, the prevalence of hyponatremia was 14.8% in patients without CKD and 12.9% in patients with CKD (P?=?0.034). In the adult group, the prevalence of hypernatremia was 0.7% in patients without CKD and 2.0% in patients with CKD (P?=?0.003). Similarly, in the elderly group, the prevalence of hypernatremia was 1.5% in patients without CKD and 3.5% in patients with CKD (P?<?0.001).Conclusion
In elderly patients, the prevalence of hyponatremia was higher in patients without CKD than in patients with CKD. Special attention should be paid to elderly patients without CKD in order to prevent severe hyponatremia. 相似文献9.
Andrew S Allegretti David JR Steele Jo Ann David-Kasdan Ednan Bajwa John L Niles Ishir Bhan 《Critical care (London, England)》2013,17(3):R109
Introduction
Continuous renal replacement therapy (CRRT) is a widely used but resource-intensive treatment. Despite its broad adoption in intensive care units (ICUs), it remains challenging to identify patients who would be most likely to achieve positive outcomes with this therapy and to provide realistic prognostic information to patients and families.Methods
We analyzed a prospective cohort of all 863 ICU patients initiated on CRRT at an academic medical center from 2008 to 2011 with either new-onset acute kidney injury (AKI) or pre-admission end-stage renal disease (ESRD). We examined in-hospital and post-discharge mortality (for all patients), as well as renal recovery (for AKI patients). We identified prognostic factors for both in-hospital and post-discharge mortality separately in patients with AKI or ESRD.Results
In-hospital mortality was 61% for AKI and 54% for ESRD. In patients with AKI (n = 725), independent risk factors for mortality included age over 60 (OR 1.9, 95% CI 1.3, 2.7), serum lactate over 4 mmol/L (OR 2.2, 95% CI 1.5, 3.1), serum creatinine over 3 mg/dL at time of CRRT initiation (OR 0.63, 95% CI 0.43, 0.92) and comorbid liver disease (OR 1.75, 95% CI 1.1, 2.9). Among patients with ESRD (n = 138), liver disease was associated with increased mortality (OR 3.4, 95% CI 1.1, 11.1) as was admission to a medical (vs surgical) ICU (OR 2.2, 95% CI 1.1, 4.7). Following discharge, advanced age became a predictor of mortality in both groups (AKI: HR 1.9, 95% CI 1.2, 3.0; ESRD: HR 4.1, 95% CI 1.5, 10.9). At the end of the study period, only 25% (n = 183) of patients with AKI achieved dialysis-free survival.Conclusions
Among patients initiating CRRT, risk factors for mortality differ between patients with underlying ESRD or newly acquired AKI. Long-term dialysis-free survival in AKI is low. Providers should consider these factors when assessing prognosis or appropriateness of CRRT. 相似文献10.
Vincent Gourhant Olivier Vuillot Pierre-Géraud Claret Sophie Lefebvre Roxane Schaub Alexandre Flacher Richard Dumont Mustapha Sebbane 《The American journal of emergency medicine》2019,37(1):67-72
Introduction
Obese patients with acute dyspnea may be prone to misorientation from the emergency department (ED), due to impaired gas exchange evaluation and altered basal respiratory profiles. This study aims to evaluate the prognostic value of arterial blood pH in obese ED patients with acute dyspnea in comparison to non-obese counterparts.Methods
Single-center observational study of a cohort of 400 consecutive ED patients with acute dyspnea. The primary endpoint was a composite of Intensive Care Unit admission (with critical care needs) or in ED mortality. Predictors of the primary endpoint were assessed using multivariable logistic regression and ROC curve analysis, in obese (BMI?≥?30?kg·m?2) and non-obese patients.Results
252 patients who had arterial blood gas testing were analyzed including 76 (30%) obese comparable to non-obese in terms of clinical history. 51 patients were admitted to ICU and 2 deceased before admission (20 obese (26%) vs 33 non-obese (19%); p?=?0.17). Factors associated with ICU admission were arterial blood pH (pH?<?7.36 vs pH?≥?7.36) and gender. In multivariate models adjusted for risk factors, pH remained the sole independent predictor in obese patients, with no predictive value in non-obese patients (ROC AUC: 0.74, 95% CI [0.60; 0.87], optimal threshold for pH: 7.36, odds ratio: 10.5 [95% CI 3.18; 34.68]).Conclusion
Arterial blood pH may selectively predict critical care needs in ED obese patients with acute dyspnea, in comparison to non-obese. A falsely reassuring pH?<?7.36 should be regarded as a marker of severity when assessing acute dyspnea in obese ED patients. 相似文献11.
Shannon M. Fernando Douglas P. Barnaby Christophe L. Herry E. John Gallagher Nathan I. Shapiro Andrew J.E. Seely 《The Journal of emergency medicine》2018,54(6):766-773
Background
Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration.Objective
Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis.Methods
We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded.Results
Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94–100%), but a sensitivity of 27% (95% CI 18–37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3–18.3) and 0.8 (95% CI 0.7–0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55–76%) and specificity of 66% (95% CI 63–69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7–2.3) and 0.5 (95% CI 0.4–0.7).Conclusions
High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration. 相似文献12.
Advanced liver fibrosis and care continuum in emergency department patients with chronic hepatitis C
Yu-Hsiang Hsieh Danielle Signer Anuj V. Patel Valentina Viertel Mustapha Saheed Risha Irvin Mark S. Sulkowski David L. Thomas Richard E. Rothman 《The American journal of emergency medicine》2019,37(2):286-290
Background
FIB-4, a non-invasive serum fibrosis index (which includes age, ALT, AST, and platelet count), is frequently available during ED visits. Our objective was to define 1-year HCV-related care outcomes of ED patients with known HCV, for the overall group, and both those with and without advanced fibrosis.Methods
As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were identified retrospectively via medical record review. Components of FIB-4 were abstracted, and patients with an FIB-4?>?3.25 were classified with advanced fibrosis and characterized with regards to downstream HCV care continuum outcomes at one-year after enrollment.Results
Of the 113 patients with known HCV, 38 (33.6%) had advanced fibrosis. One-year outcomes along the HCV care continuum after ED encounter for ‘all’ 113, 75 ‘without advanced fibrosis’, and 38 ‘advanced fibrosis’ patients, respectively, were as follows: agreeing to be linked to care [106 (93.8%), 72 (96.0%), 34 (89.5%)]; LTC [38 (33.6%), 21 (28.0%), 17 (44.7%)]; treatment initiation among those linked [16 (42.1%), 9 (42.9%), 7 (41.2%)]; sustained virologic response 4?weeks post-treatment among those treated [15 (93.8%), 9 (100.0%), 6 (85.7%)]; documented all-cause mortality [10 (8.8%), 3 (4.0%), 7 (18.4%)]. Notably, 70% of those who died had advanced fibrosis. For those with advanced liver fibrosis, all-cause mortality was significantly higher, than those without (18.4% versus 4.0%, p?=?0.030).Conclusions
Over one-third of HCV-infected ED patients have advanced liver fibrosis, incomplete LTC, and higher mortality, suggesting this readily-available FIB-4 might be used to prioritize LTC services for those with advanced fibrosis. 相似文献13.
Jui-Yuan Chung Chien-Chin Hsu Jiann-Hwa Chen Wei-Lung Chen Hung-Jung Lin How-Ran Guo Chien-Cheng Huang 《The American journal of emergency medicine》2019,37(3):391-394
Background
The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue.Methods
We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65?years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality.Results
In total, 409 geriatric ED patients with mean age of 79.5?years and nearly equal sex ratio were recruited. The mean shock index?±?standard deviation was 0.7?±?0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39–19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer–Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%.Conclusions
A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza. 相似文献14.
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15.
Nathaniel L. Scott Lauren R. Klein Ellen Cales Brian E. Driver 《The American journal of emergency medicine》2019,37(2):209-213
Introduction
Complications associated with the emergency department (ED) management of hyperkalemia are not well characterized. The goals of this study were to describe the frequency of hypoglycemia following the use of insulin to shift potassium intracellularly and to examine the association of key variables with this complication.Methods
Adult ED patients (≥18?years old) with hyperkalemia (>5.3?mmol/L) were identified in the electronic medical record over a 5-year period at the study site. Patient characteristics, laboratory results, and treatments in the ED were captured. A generalized estimating equation (GEE) model was utilized to determine independent associations with the development of hypoglycemia.Results
1307 encounters were identified where hyperkalemia was present. Hypoglycemia (defined as a glucose <70?mg/dL) occurred in 68/409 (17%) of patients given insulin, compared to 4% of patients who did not receive insulin. Lower glucose prior to insulin (adjusted odds ratio [aOR] 0.90; 95% confidence interval [95% CI] 0.85 to 0.96), higher doses of insulin (aOR 1.07; 95% CI 1.01 to 1.15) and lower doses of D50 (aOR 0.98; 95% CI 0.97 to 0.99) were independently associated with hypoglycemia in the multivariate analysis. Age, history of diabetes, and history renal failure were not independently associated.Conclusion
Hypoglycemia is a frequent complication of treatment with IV insulin in the ED. Interventions such as standardized protocols to assist with the ED management of hyperkalemia should be developed; their efficacy and safety should be compared. 相似文献16.
Eileen Shu Leyla Farshidpour Megann Young Michael Darracq Crystal Ives Tallman 《The American journal of emergency medicine》2019,37(3):502-505
Background
Synovial lactate is a promising biomarker to distinguish septic from aseptic arthritis. If available as a point-of care test, synovial lactate would be rapidly available to aid the emergency provider in clinical decision making. This study assesses the test characteristics of synovial lactate obtained using an EPOC© point-of-care (POC) analyzer to rapidly distinguish septic from aseptic arthritis in the emergency department.Methods
We enrolled a convenience sample of patients with possible septic arthritis presenting to the emergency department at a large urban academic center between October 2016 and April 2018. Enrolled patients underwent arthrocentesis based on the clinical judgment of the treating provider. We obtained synovial lactate levels (SLL) from the POC device. Standard laboratory analysis, synovial fluid culture, emergency and hospital course, operative procedures, antibiotics, and discharge diagnosis were abstracted from the electronic medical record.Results
Thirty-nine patients undergoing forty separate arthrocentesis procedures were enrolled in this study over the two-year period. The sensitivity and specificity of SLL?≥?5?mmol/L was 0.55 and 0.76 respectively, with +LR 2.3 and ?LR 0.6. The sensitivity and specificity of SLL?≥?10?mmol/L was 0.27 and 0.97 respectively, with +LR 7.9 and ?LR 0.8; SLL?≥?10?mmol/L performed similarly to overall synovial WBC?≥?50,000/μL by conventional laboratory testing.Conclusion
It is feasible to obtain a synovial lactate level using the EPOC© POC device. In our study, POC SLL performs similarly to other markers used to diagnose septic arthritis. Further study with larger sample sizes is warranted. 相似文献17.
Ayman El-Menyar Brijesh Sathian Bianca M. Wahlen Hassan Al-Thani 《The American journal of emergency medicine》2019,37(1):133-142
Objective
The association between brain injury and elevated serum cardiac troponin (cTn) remains poorly understood. We conducted a systematic review and meta-analysis to evaluate whether elevated cTn increases the risk of mortality in patients with traumatic (TBI) or non-traumatic brain injury (NT-BI).Methods
Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google scholar databases, and clinicaltrials.gov were searched for a retrospective, prospective and randomized clinical trials (RCT) or quasi-RCT studies that assessed the effect of elevated cTn (conventional or high sensitive assay) on the outcomes of brain injury patients. The main outcome of interest was mortality. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for analysis, whenever appropriate. The total number of patients pooled was 2435, of which 916 had elevated cTn and 1519 were in control group.Results
Out of 691 references identified through the search, 8 analytical studies met inclusion criteria. Among both types of brain injuries, an elevated cTn was associated with a higher mortality with an overall pooled odd ratio (OR) of 3.37 (95% CI 2.13–5.36). The pooled OR for mortality was 3.31 (95% CI 1.99–5.53) among patients with TBI and 3.36 (95% CI 1.32–8.6) among patients with NT-BI.Conclusions
Pooled analysis indicates that elevated cTn is significantly associated with a high mortality in patients with TBI and NT-BI. Prospective clinical trials are needed to support these findings and to inform a biomarker risk stratification regardless of the mechanism of injury. 相似文献18.
Sameer Sharif Michelle Eventov Clive Kearon Sameer Parpia Meirui Li River Jiang Paula Sneath Carmen Otero Fuentes Christopher Marriott Kerstin de Wit 《The American journal of emergency medicine》2019,37(5):845-850
Background
Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific.Objective
We compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients.Design/methods
We performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30?days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule.Results
1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6–73.0%), 80.3% (95% CI 77.9–82.6%) and 68.9%; (95% CI 65.7–71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0–99.9%), 99.1% (95% CI 98.3–99.5%) and 100% (95% CI 99.4–100.0%) respectively.Conclusion
The clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value. 相似文献19.
20.
Kamal Maheshwari Brian H. Nathanson Sibyl H. Munson Victor Khangulov Mitali Stevens Hussain Badani Ashish K. Khanna Daniel I. Sessler 《Intensive care medicine》2018,44(6):857-867