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1.
Purpose
Emergency department (ED) patients frequently estimate blood loss. How such information should guide evaluation and management, however, is unclear. The objective of this study was to examine ED patient accuracy in estimating blood loss on different surfaces.Methods
A convenience sample of 100 ED patients were asked to estimate the amount of moulage blood present in 4 scenarios: 178 mL spilled in a baking sheet on the floor; 5 mL in 2.5 mL of mucous in a tissue; 119 mL on a t-shirt; and 119 mL in a commode filled with water.Results
The mean percent error for all estimates was 412% with a range of 0% to 1080%. Estimates were within 100% of the actual amount 44% of the time. Eleven percent of assessments were correct and 70% were overestimates.Conclusion
Emergency department patients do not estimate blood loss well in a variety of scenarios, erring on the side of overestimation. 相似文献2.
3.
Background
Myocarditis can be difficult to diagnose in the Emergency Department (ED) due to the lack of classic symptoms and the wide variation in presentations. Poor cardiac contractility is a common finding in myocarditis and can be evaluated by bedside ultrasound.Objective
To demonstrate the utility of fractional shortening measurements as an estimation of left ventricular function during bedside cardiac ultrasound evaluation in the ED.Case Report
A 54-year-old man presented to the ED complaining of 3 days of chest tightness, palpitations, and dyspnea, as well as persistent abdominal pain and vomiting. An electrocardiogram (ECG) showed sinus tachycardia with presumably new ST-segment elevation and signs of an incomplete right bundle branch block. A bedside echocardiogram was performed by the emergency physician that showed poor left ventricular function by endocardial fractional shortening measurements. On further questioning, the patient revealed that for the past 2 weeks he had been regularly huffing a commercially available compressed air duster. Based on these history and examination findings, the patient was given a presumptive diagnosis of toxic myocarditis. A follow-up echocardiogram approximately 7 weeks later demonstrated resolution of the left ventricular systolic dysfunction and his ECG findings normalized.Conclusion
Cardiac ultrasound findings of severely reduced global function measured by endocardial fractional shortening were seen in this patient and supported the diagnosis of myocarditis. Endocardial fractional shortening is a useful means of easily evaluating and documenting left ventricular function and can be performed at the bedside in the ED. 相似文献4.
Background
Focused bedside ultrasound is a screening tool frequently used by emergency physicians to evaluate hepatobiliary and renal pathology in patients presenting with abdominal complaints in the emergency department (ED).Objective
This case report describes a sonographic finding that was interpreted as free fluid in the right upper quadrant. Computed tomography (CT) was used to confirm the diagnosis.Case Report
A 44-year-old man presented to the ED with the sudden onset of right-sided abdominal pain and exhibited right costovertebral angle tenderness on physical examination. Focused bedside ultrasound of the right upper quadrant revealed severe hydronephrosis of the right kidney and free fluid of either subcapsular, perinephric, or peritoneal location represented by an anechoic stripe in Morison’s pouch. On CT evaluation, this patient was found to have perinephric fluid accumulation from a presumed ruptured renal calyx in the setting of chronic ureteropelvic junction obstruction with severe hydronephrosis.Conclusion
The exact location of anechoic fluid in the abdomen is not always apparent on bedside ultrasound. To minimize misinterpreting focused bedside ultrasound examination findings, we recommend a number of sonographic techniques to identify possible mimics of free fluid. Suspected free fluid findings on bedside ultrasound should always be evaluated within the clinical context of the patient’s presentation. 相似文献5.
Background
Rapid Response Teams aim to accelerate recognition and treatment of acutely unwell patients. Delays in delivery might undermine efficiency of the intervention. Our understanding of the causes of these delays is, as yet, incomplete.Aim
To identify modifiable causes of delays in the treatment of critically ill patients outside intensive care with a focus on factors amenable to system design.Methods
Review of care records and direct observation with process mapping of care delivered to 17 acutely unwell patients attended by a Rapid Response Team in a District General Hospital in the United Kingdom. Delays were defined as processes with no added value for patient care.Results
Essential diagnostic and therapeutic procedures accounted for only 31% of time of care processes. Causes for delays could be classified into themes as (1) delays in call-out of the Rapid Response Team, (2) problems with team cohesion including poor communication and team efficiency and (3) lack of resources including lack of first line antibiotics, essential equipment, experienced staff and critical care beds.Conclusion
We identified a number of potentially modifiable causes for delays in care of acutely ill patients. Improved process design could include automated call-outs, a dedicated kit for emergency treatment in relevant clinical areas, increased usage of standard operating procedures and staff training using crew resource management techniques. 相似文献6.
Background
Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).Objectives
OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.Case Report
We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.Conclusions
This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography. 相似文献7.
Conor J. McKaigney Mori J. Krantz Cherie L. La Rocque Nicole D. Hurst Matthew S. Buchanan John L. Kendall 《The American journal of emergency medicine》2014
Objectives
Rapid assessment of left ventricular ejection fraction (LVEF) may be critical among emergency department (ED) patients. This study examined the predictive relationship between ED physician performed bedside mitral-valve E-point septal separation (EPSS) measurements to the quantitative, calculated LVEF. We further evaluated the relationship between ED physician visual estimates of global cardiac function (GCF) and calculated LVEF values.Methods
A prospective observational study was conducted on a sequential convenience sample of patients receiving comprehensive transthoracic echocardiography (TTE). Three ED ultrasound fellows performed bedside ultrasound examinations to obtain both EPSS measurements and subjective visual GCF estimates. A linear regression analysis was conducted to examine the relation of EPSS to the calculated LVEF from the comprehensive TTE. Agreement (modified Cohen κ) between ED ultrasound fellow GCF estimates and the calculated LVEF was also assessed.Results
Linear regression analyses revealed a significant correlation (r = 0.73, P < .001) between bedside EPSS and the calculated LVEF. The sensitivity and specificity of an EPSS measurement of greater than 7 mm for severe systolic dysfunction (LVEF ≤ 30%) were 100.0% (95% confidence interval, 62.9-100.0) and 51.6% (95% confidence interval, 38.6-64.5), respectively. Subjective estimates of GCF were moderately correlated with calculated LVEF (Cohen κ = 0.58).Conclusions
Measurements of EPSS by ED physicians were significantly associated with the calculated measurements of LVEF from comprehensive TTE. Subjective visual estimates of GCF, however, demonstrated only moderate agreement with the calculated LVEF. An EPSS measurement greater than 7 mm was uniformly sensitive at identifying patients with severely reduced LVEF. 相似文献8.
9.
Jiraporn Sri-On Yuchiao Chang David P. Curley Carlos A. Camargo Jr. Joel S. Weissman Sara J. Singer Shan W. Liu 《The American journal of emergency medicine》2014
Background
Hospital crowding and emergency department (ED) boarding are large and growing problems. To date, there has been a paucity of information regarding the quality of care received by patients boarding in the ED compared with the care received by patients on an inpatient unit. We compared the rate of delays and adverse events at the event level that occur while boarding in the ED vs while on an inpatient unit.Methods
This study was a secondary analysis of data from medical record review and administrative databases at 2 urban academic teaching hospitals from August 1, 2004, through January 31, 2005. We measured delayed repeat cardiac enzymes, delayed partial thromboplastin time level checks, delayed antibiotic administration, delayed administration of home medications, and adverse events. We compared the incidence of events during ED boarding vs while on an inpatient unit.Results
Among 1431 patient medical records, we identified 1016 events. Emergency department boarding was associated with an increased risk of home medication delays (risk ratio [RR], 1.54; 95% confidence interval [CI], 1.26-1.88), delayed antibiotic administration (RR, 2.49; 95% CI, 1.72-3.52), and adverse events (RR, 2.36; 95% CI, 1.15-4.72). On the contrary, ED boarding was associated with fewer delays in repeat cardiac enzymes (RR, 0.17; 95% CI, 0.09-0.27) and delayed partial thromboplastin time checks (RR, 0.54; 95% CI, 0.27-0.96).Conclusion
Compared with inpatient units, ED boarding was associated with more medication-related delays and adverse events but fewer laboratory-related delays. Until we can eliminate ED boarding, it is critical to identify areas for improvement. 相似文献10.
Zoe D. Howard Vicki E. Noble Keith A. Marill Dana Sajed Marcio Rodrigues Bianca Bertuzzi Andrew S. Liteplo 《The Journal of emergency medicine》2014
Background
Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS).Objectives
Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination.Methods
We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale.Results
Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey.Conclusions
Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys. 相似文献11.
Medley DB Morris JE Stone CK Song J Delmas T Thakrar K 《The Journal of emergency medicine》2012,43(4):736-744
Background
Studies have explored possible causes of violent acts in the emergency department (ED), however, the association of violence with ED crowding has not been studied. Although the total number of violent acts would be expected to increase, it is not clear if the rate of violent acts also increases as occupancy levels rise.Objective
The purpose of this study was to determine if there is an association between occupancy rates in the ED and rates of violence toward staff.Methods
This was a retrospective chart review study. Violent incidents in a community, Level I trauma center ED were identified from review of orders of emergency detainment, adverse event forms, physical restraint logs, and pharmacy records from January 1, 2005 to June 1, 2008. Occupancy rates for all days were calculated and violent vs. non-violent days were compared using a standard two-sample t-test. Logistic regression analysis was then used to investigate other factors associated with violent incidents.Results
A rate of violence of 1.3 incidents per 1000 patients was found. When comparing the occupancy rates of violent days (mean 95%, SD 26%) with non-violent days (mean 86%, SD 24%), a statistically significant association was found (p < 0.0001). Multivariate logistic regression confirmed a significant association between crowding and violence toward staff (odds ratio 4.290, 95% confidence interval 2.137–8.612).Conclusion
These results suggest another possible negative effect that crowding has on ED staff and physicians. Policies and recommendations regarding ED operating procedures and staff safety during times of higher occupancy levels should be discussed. 相似文献12.
Is female sex associated with ED delays to diagnosis of appendicitis in the computed tomography era?
Sarah McGann Donlan MD Mark B. Mycyk MD 《The American journal of emergency medicine》2009,27(7):856-858
Background
Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery.Objective
The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era.Methods
A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data.Results
One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order.Conclusion
Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis. 相似文献13.
Background
Disruptive behaviors have been shown to have a significant negative impact on staff collaboration and clinical outcomes of patient care. Disruptive episodes are more likely to occur in high stress areas such as the Emergency Department (ED). Having the structure, process, and skills in place to effectively address this issue will lower the likelihood of preventable adverse events.Objectives
To assess the status of disruptive behaviors and staff relationships in the ED setting.Methods
A 23-question survey tool was distributed to a regional group of ED physicians, nurses, and staff members to assess their perceptions as to the incidence of discipline-specific occurrences, types and impact of disruptive behaviors on staff behaviors, communication efficiency, and patient outcomes of care.Results
A total of 370 surveys were received. Fifty-seven percent witnessed the disruptive behaviors by physicians, 52% witnessed the disruptive behaviors by nurses; 32.8% of the respondents felt that disruptive behavior could be linked to the occurrence of adverse events, 35.4% to medical errors, 24.7% to compromises in patient safety, 35.8% to poor quality, and 12.3% to patient mortality. Eighteen percent reported that they were aware of a specific adverse event that occurred as a direct result of disruptive behavior.Conclusion
Disruptive behaviors in the ED have a significant impact on team dynamics, communication efficiency, information flow, and task accountability, all of which can adversely impact patient care. EDs need to recognize the significance of disruptive behaviors and implement appropriate policies and protocols to address this issue. 相似文献14.
Niccolò Parri MD Bradley J. Crosby Casey Glass Francesco Mannelli Idanna Sforzi Raffaele Schiavone Kevin Michael Ban 《The Journal of emergency medicine》2013
Background
Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.Objectives
Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.Methods
We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.Results
Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.Conclusions
Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation. 相似文献15.
Background
Soft tissue injury with a retained foreign body (FB) is a common emergency department (ED) complaint. Detection and precise localization of these foreign bodies is often difficult with traditional plain radiographic imaging or computed tomography (CT).Case Report
We present three cases in which bedside ultrasound was used to identify and guide management of retained soft tissue foreign bodies. Comparison of ultrasound vs. plain radiography and CT, as well as techniques for FB identification and removal, are discussed.Why should an emergency physician be aware of this?
Bedside ultrasound is an invaluable tool in the localization of foreign bodies in relation to other anatomic structures, and aids in the decision to remove them in the ED. 相似文献16.
Stefano Parlamento Roberto Copetti Stefano Di Bartolomeo 《The American journal of emergency medicine》2009
Objectives
The aim of this study is to assess the ability of bedside lung ultrasound (US) to confirm clinical suspicion of pneumonia and the feasibility of its integration in common emergency department (ED) clinical practice.Methods
In this study we performed lung US in adult patients admitted in our ED with a suspected pneumonia.Subsequently, a chest radiograph (CXR) was carried out for each patient. A thoracic computed tomographic (CT) scan was made in patients with a positive lung US and a negative CXR. In patients with confirmed pneumonia, we performed a follow-up after 10 days to evaluate clinical conditions after antibiotic therapy.Results
We studied 49 patients: pneumonia was confirmed in 32 cases (65.3%). In this group we had 31 (96.9%) positive lung US and 24 (75%) positive CXR. In 8 (25%) cases, lung US was positive with a negative CXR. In this group, CT scan always confirmed the US results. In one case, US was negative and CXR positive. Follow-up turned out to be always consistent with the diagnosis.Conclusion
Considering that lung US is a bedside, reliable, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of pneumonia in the ED, even if no sensitivity nor specificity can be inferred from this study because the real gold standard is CT, which could not be performed in all patients. 相似文献17.
Purpose
Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED.Basic Procedures
This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005.Main Findings
Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition.Conclusions
The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research. 相似文献18.
Gabriel Wardi Paul Ishimine Daniel Lasoff Chao Yuan Colleen Campbell 《The Journal of emergency medicine》2014
Background
Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition.Case Report
A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture.Why Should an Emergency Physician Be Aware of This?
Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population. 相似文献19.
Background
Retinal detachment is a true medical emergency. It is a time-critical, vision-threatening disease often first evaluated in the Emergency Department (ED). Diagnosis can be extremely challenging and confused with other ocular pathology. Several entities can mimic retinal detachment, including posterior vitreous detachment and vitreous hemorrhage. Ocular ultrasound can assist the emergency physician in evaluating intraocular pathology, and it is especially useful in situations where fundoscopic examination is technically difficult or impossible. Accurate and rapid diagnosis of retinal detachment can lead to urgent consultation and increase the likelihood of timely vision-sparing treatment.Objectives
This case demonstrates both the utility of ocular ultrasound in the accurate and timely diagnosis of retinal detachment and potential pitfalls in the evaluation of intraocular pathology in the ED.Case Report
A 38-year-old woman presented with acute onset of bilateral visual loss that was concerning for retinal detachment. Rapid evaluation of the intraocular space was performed using bedside ocular ultrasound. Bedside ocular ultrasound correctly diagnosed retinal detachment in the right eye. Posterior vitreous detachment in the left eye was incorrectly diagnosed as retinal detachment.Conclusion
This case illustrates the importance of bedside ocular ultrasound and highlights some of the pitfalls that can occur when evaluating for retinal detachment. Following is a discussion regarding methods to distinguish retinal detachment from vitreous hemorrhage and posterior vitreous detachment. 相似文献20.
Amish Shah MD MPH Makini Chisolm-Straker Aeri AlexanderAlex F. Manini MD MS 《The American journal of emergency medicine》2014