共查询到20条相似文献，搜索用时 31 毫秒
1.
Anna Marie Chang Judd E. Hollander Erica Su Robert E. Weiss Annick N. Yagapen Susan E. Malveau David H. Adler Aveh Bastani Christopher W. Baugh Jeffrey M. Caterino Carol L. Clark Deborah B. Diercks Bret A. Nicks Daniel K. Nishijima Manish N. Shah Kirk A. Stiffler Alan B. Storrow Scott T. Wilber Benjamin C. Sun 《The American journal of emergency medicine》2019,37(5):869-872
Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode.
Methods
This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60?years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events.Results
The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30?days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90–1.31; p?=?0.387).Conclusion
In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events. 相似文献2.
Background
Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope.Methods
We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60?years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit.Results
While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129.Conclusion
Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope. 相似文献3.
Zardasht Oqab Heather Ganshorn Robert Sheldon 《The American journal of emergency medicine》2018,36(4):551-555
Background
Syncope is a common clinical presentation and establishing an etiology is often challenging. Pulmonary embolism (PE) has been thought to be an uncommon cause but a recent report suggested otherwise.Objective
To establish the prevalence of PE in patients presenting with syncope to the emergency department (ED) and in hospitalized patients.Methods
We systematically searched Medline, CINAHL, EMBASE, LILACS and Web of Science with relevant keywords and MeSH headings for syncope and PE. Inclusion criteria were patients presenting with syncope to ED or hospitalized due to syncope, and etiologies including PE.Results
Of 1329 titles and abstracts, 12 (other than Prandoni et al.) met inclusion criteria. Nine studies included 6608 ED patients and 3 included 975 hospitalized patients. The mean age was 62 (95% CI 54–69) for ED patients and 67 (95% CI 64–70) for hospitalized. The pooled estimate of PE prevalence in ED syncope patients was 0.8% (95% CI 0.5–1.3%, I2 = 0%). The pooled estimate of PE prevalence in hospitalized patients was 1.0% (95% CI 0.5–1.9%, I2 = 0). In contrast, the prevalence of PE in Prandoni et al. were 3.8% and 17.3% for ED and hospitalized patients respectively, both significantly higher than in other relevant studies (p < 0.0001).Conclusion
The estimated prevalence of PE in patients presenting with syncope is low. The Prandoni et al. estimates are significantly higher, suggesting a possible site effect, accrual bias, or investigation strategy. These and the prognostic impact of higher PE prevalence require understanding before changes in practice. 相似文献4.
Alison Frizell Nicole Fogel Jacob Steenblik Margaret Carlson Joseph Bledsoe Troy Madsen 《The American journal of emergency medicine》2018,36(2):253-256
Objectives
A recent study reported a high prevalence of pulmonary embolism (PE) among patients admitted with syncope. We sought to determine whether these findings were validated in our patient population.Methods
We performed a retrospective, secondary analysis of prospectively gathered data from patients presenting with syncope to an academic emergency department (ED) from July 2010 to December 2015. We analyzed baseline information from the time of the ED visit, recorded outcomes during the hospital stay, and contacted patients by phone at least 30 days after the ED visit. The primary study outcome was the diagnosis of acute PE in the ED, during inpatient admission or ED observation unit stay, or by patient report over a 30-day follow-up period.Results
Over the 5.5-year study period, 348 patients with syncope agreed to participate in the study. 52% of patients were female [95% confidence interval (CI): 46.6–57.4] and the average age was 48.4 years. Of the enrolled patients, 50.1% (CI: 44.8–55.2) underwent further evaluation for syncope beyond the ED stay: 27% (CI: 22.6–31.9) of patients were admitted to an inpatient unit for further work-up and 23.9% (CI: 19.7–28.6) of patients were placed in the ED observation unit. The overall rate of PE among patients presenting to the ED with syncope was 1.4% (CI: 0.6–3.3%). 2 patients (0.6%, CI: 0.2–2.1) were diagnosed with a PE while in the ED. None of the patients were diagnosed with a PE during hospital admission or the observation stay associated with the index ED visit. 3 patients (0.9%, CI: 0.3–2.5) reported they had been diagnosed with a PE during the 30 days following their ED visit, two of whom had been admitted to the hospital at the index ED visit but were not diagnosed with a PE at that time. All patients diagnosed with a PE at the time of the ED visit or during the follow-up period were Pulmonary Embolism Rule Out Criteria (PERC) positive and reported shortness of breath in the ED.Conclusion
In contrast to a previous study, our findings do not support a high rate of PE among ED patients presenting with syncope. 相似文献5.
Anand M. Prabhakar Ravi V. Gottumukkala Jennifer Hemingway Danny R. Hughes Sumir S. Patel Richard Duszak 《The American journal of emergency medicine》2018,36(4):680-683
Objective
To assess for changes in emergency department (ED) utilization of neuroimaging in Medicare fee-for-service beneficiaries from 1994 to 2015.Methods
Using Medicare Physician Supplier Procedure Summary Master Files, annual ED volumes of head computed tomography (CT), magnetic resonance (MR), and carotid duplex ultrasound (CDUS) were assessed from 1994 through 2015. Annual volumes of head CT angiography (CTA), neck CTA, head MR angiography (MRA), and neck MRA studies were assessed from 2001 (first year of unique reporting codes) through 2015. Longitudinal population-based utilization rates were calculated using annual Medicare Part B enrollment, and utilization rates were normalized annually per 1000 ED visits.Results
From 1994 through 2015, ED neuroimaging utilization rates per 1000 ED visits increased 660% overall (compound annual growth rate [CAGR] 9%); 529% for head CT (CAGR 9%); 1451% for head MRI (CAGR 14%); and by 104% for CDUS (CAGR 3%). From 2001 to 2015, rates increased 14,600% (CAGR 43%) and 17,781% (CAGR 45%) for head and neck CTA, respectively, and 525% (CAGR 14%) and 667% (CAGR 16%) for head and neck MRA, respectively. Trends were similar when volumes were normalized for annual Medicare fee-for-service enrollment. Non-contrast head CT was the most common imaging modality throughout the study period (86% of annual neuroimaging volume in 1994; 89% in 2015).Conclusions
In Medicare beneficiaries, neuroimaging utilization in the ED grew unabated from 1994 through 2015, with growth of head and neck CTA far outpacing other modalities. Non-contrast head CT remains by far the dominant ED neuroimaging examination. 相似文献6.
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7.
Tae Han Kim Ki Jeong Hong Sang Do Shin Gwan Jin Park Sungwan Kim Nhayoung Hong 《The American journal of emergency medicine》2019,37(2):183-188
Background
Monitoring and detecting sudden outbreaks of respiratory infectious disease is important. Emergency Department (ED)-based syndromic surveillance systems have been introduced for early detection of infectious outbreaks. The aim of this study was to develop and validate a forecasting model of respiratory infectious disease outbreaks based on a nationwide ED syndromic surveillance using daily number of emergency department visits with fever.Methods
We measured the number of daily ED visits with body temperature?≥?38.0?°C and daily number of patients diagnosed as respiratory illness by the ICD-10 codes from the National Emergency Department Information System (NEDIS) database of Seoul, Korea. We developed a forecast model according to the Autoregressive Integrated Moving Average (ARIMA) method using the NEDIS data from 2013 to 2014 and validated it using the data from 2015. We defined alarming criteria for extreme numbers of ED febrile visits that exceed the forecasted number. Finally, the predictive performance of the alarm generated by the forecast model was estimated.Results
From 2013 to 2015, data of 4,080,766 ED visits were collected. 303,469 (7.4%) were ED visits with fever, and 388,943 patients (9.5%) were diagnosed with respiratory infectious disease. The ARIMA (7.0.7) model was the most suitable model for predicting febrile ED visits the next day. The number of patients with respiratory infectious disease spiked concurrently with the alarms generated by the forecast model.Conclusions
A forecast model using syndromic surveillance based on the number of ED visits was feasible for early detection of ED respiratory infectious disease outbreak. 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.
11.
Sachita P. Shah Kevin Penn Stephen J. Kaplan Michael Vrablik Karl Jablonowski Tam N. Pham May J. Reed 《The American journal of emergency medicine》2019,37(1):12-18
Background
Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED).Methods
We recruited a convenience sample of adults 65?yrs. or older with blunt trauma and injury severity scores <9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC).Results
Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84–0.98] or physician (AUROC 0.77 [95% CI 0.63–0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores <4, sensitivity and negative predictive value were 90.0% (54.1–99.5%) and 95.0% (73.1–99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard.Conclusion
The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history. 相似文献12.
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13.
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14.
Kevin Yeboah Aakash Bodhit Ali Al Balushi Erik Krause Abhay Kumar 《The American journal of emergency medicine》2019,37(2):308-311
Introduction
Diagnosis of acute ischemic stroke is critical for acute intervention. Its diagnosis may be obscured in trauma patients due to confounding injuries. We report its incidence in trauma patients following their presentation at our institution.Methods
Electronic charts of all acute trauma patients presenting to a designated level 1 trauma center emergency department between September 2012–November 2015 were screened and included in the study if they had a discharge diagnosis of acute ischemic stroke. Patient data were reviewed to identify the presence of neurologic deficit on initial triage, imaging type obtained (intracranial or extracranial) and time to diagnosis of stroke.Results
Of 192 trauma patients screened, 11 were found to have acute ischemic stroke (5.7%). Patients were generally young (median age, 49?years) and predominantly males (n?=?8). Presentation after vehicular crash was most frequent (n?=?8 or 73%). Patients had predominantly skeletal injuries (n?=?8 or 73%). Initial workup involved vascular imaging below the neck (n?=?9), while only one had intracranial vascular imaging. When patients underwent cervicocranial vascular imaging, 64% (n?=?7) had findings explaining the etiology of their stroke. None of the patients was diagnosed with acute ischemic stroke on admission. Its diagnosis was delayed by an average 1.8?days following presentation.Conclusions
Acute ischemic stroke in trauma patients was a frequent diagnosis albeit with delay. Routine craniocervical vascular imaging at the time of presentation could potentially facilitate early diagnosis. A prospective study with routine craniocervical vascular imaging in trauma patients will be needed to further explore this hypothesis. 相似文献15.
Trauma team activation criteria and outcomes of geriatric trauma: 10 year single centre cohort study
Kevin Kei-ching Hung Janice H.H. Yeung Catherine S.K. Cheung Ling-yan Leung Raymond C.H. Cheng N.K. Cheung Colin A. Graham 《The American journal of emergency medicine》2019,37(3):450-456
Background
With the aging population, the number of older patients with multiple injuries is increasing. The aim of this study was to understand the patterns and outcomes of older patients admitted to a major trauma centre in Hong Kong from 2006 to 2015, and investigate the performance of the trauma team activation (TTA) criteria for these elderly patients.Methods
This was a retrospective cohort study from a university hospital major trauma centre in Hong Kong from 2006 to 2015. Patients aged 55 or above who entered the trauma registry were included. Patients were divided into those aged 55–70, and above 70. To test the performance of the TTA criteria, we defined injured patients with severe outcomes as those having any of the following: death within 30?days; the need for surgery; or the need for intensive care unit (ICU) care.Results
2218 patients were included over the 10?year period. The 30-day mortality was 7.5% for aged 55–70 and 17.7% for those aged above 70. The sensitivity of TTA criteria for identifying severe outcomes for those aged 55 or above was 35.6%, with 91.6% specificity. The under-triage rate was 59% for age 55–70, and 69.1% for those aged above 70.Conclusion
There is a need to consider alternative TTA criteria for our geriatric trauma population, and to more clearly define the process and standards of care in Hong Kong. 相似文献16.
17.
Michelle Ng Jerrold Perrott Sarah Burgess 《The American journal of emergency medicine》2019,37(3):444-449
Introduction
Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3?h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated.Methods
This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90?mm?Hg and/or heart rate >110?bpm and presentation within 8?h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3?h from injury.Results
During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3?h. 22 patients (19%) received TXA as a pre-hospital dose.Conclusions
<10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3?h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required.Level of evidence
IIIStudy type
Therapeutic 相似文献18.
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20.
Maryam Boumezrag Sormeh Harounzadeh Hamza Ijaz Angeline Johny Lorna Richards Yan Ma Maxine A. Le Saux Paige Kulie Caitlin Davis Andrew C. Meltzer 《The American journal of emergency medicine》2019,37(2):304-307