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Journal Open Access Emergency Medicine

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144 articles
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Bardia Barimani, Rayan Fairag, Fahad Abduljabbar, Ahmed Aoude, Carlo Santaguida, Jean Ouellet, Michael Weber
Open Access Emergency Medicine, Volume 11, pp 39-42; doi:10.2147/oaem.s149296

Abstract:A missed traumatic atlanto-axial rotatory subluxation in an adult patient: case report Bardia Barimani,1 Rayan Fairag,1,2 Fahad Abduljabbar,1,2 Ahmed Aoude,1 Carlo Santaguida,1 Jean Ouellet,1 Michael Weber1 1McGill Scoliosis and Spine Centre, McGill University Health Centre, Montreal, QC, Canada; 2Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia Background: Traumatic atlanto-axial rotatory subluxation (AARS) in an adult is a rare condition, which if left untreated can be fatal. In addition to this, many symptoms experienced such as neck pain and stiffness are non-specific which often leads to misdiagnosis, thus delaying definitive treatment. AARS can be divided into traumatic and non-traumatic causes with the latter generally encompassing congenital cervical spine abnormalities. Case presentation: We present a case of a 66-year-old female with traumatic rotatory AARS, which was initially misdiagnosed in the emergency department. This patient was subsequently recalled to the hospital when the misdiagnosis was spotted the following day from imaging results. The patient was initially managed conservatively as an inpatient using head halter cervical traction which proved to give good clinical reduction allowing discharge with Miami J upon ambulation. Upon follow up the patient was experiencing continuous pain but remained neurovascularly intact. She thus opted for definitive management with C1–C2 stabilization with an open reduction and internal fixation. Conclusion: This case demonstrates the importance of having a high index of suspicion to diagnose AARS in cervical spine trauma presenting to the emergency department, until exclusion can be made using imaging and clinical examination. Keywords: atlanto-axial subluxation, torticollis, atlanto-axial joint, atlanto-axial fixation, rotatory, traumatic
Open Access Emergency Medicine; doi:10.2147/oaem

Reza Mosaddegh, Neda Ashayeri, Mahdi Rezai, Gholamreza Masoumi, Samira Vaziri, Fatemeh Mohammadi, Hamed Givzadeh, Nasrin Noohi
Open Access Emergency Medicine, Volume 11, pp 9-13; doi:10.2147/oaem.s180398

Abstract:Are serial hematocrit measurements sensitive enough to predict intra-abdominal injuries in blunt abdominal trauma? Reza Mosaddegh,1 Neda Ashayeri,2 Mahdi Rezai,1 Gholamreza Masoumi,3 Samira Vaziri,1 Fatemeh Mohammadi,4 Hamed Givzadeh,5 Nasrin Noohi1 1Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran; 2Department of Pediatric Hematology and Oncology, Ali Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran; 3Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran; 4Research and Development Center of Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran; 5Orthopedic Research Center, Guilan University of Medical Sciences, Rasht, Iran Objective: Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in predicting the probable injuries in blunt abdominal trauma. Materials and method: We performed a prospective study of trauma patients admitted in our observation unit over a 12-month period. Patients routinely underwent serial hematocrit testing in 6-hour intervals (two hematocrit levels). We compared trauma patients with a hematocrit drop of 5 and 10 points or more to those without a significant hematocrit drop. Results: Five hundred forty-two isolated blunt abdominal trauma patients were admitted to observation unit, and 468 patients (86.35%) had serial hematocrit during their 6-hour stay. Of these patients, 36.11% had a hematocrit drop of 5 or more and 12.61% a drop of 10 or more. Of patients with the hematocrit drop >10, 50.8% have had diagnostic manifestations of intra-abdominal injury in both ultrasonographic and computed tomography scanning (P5 and positive imaging. Conclusion: Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center’s observation unit did not significantly aid in the prediction of occult injuries. Keywords: Blunt abdominal trauma, serial hematocrit, ultrasonography, computed tomography
Lesley A. Osborn, Megan L. Brenner, Samuel J. Prater, Laura J. Moore
Open Access Emergency Medicine, Volume 11, pp 29-38; doi:10.2147/oaem.s166087

Abstract:Resuscitative endovascular balloon occlusion of the aorta: current evidence Lesley A Osborn,1 Megan L Brenner,2 Samuel J Prater,1 Laura J Moore3 1Department of Emergency Medicine, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA; 2Department of Surgery, The University of California – Riverside, Moreno Valley, CA, USA; 3Department of Surgery, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use. Keywords: REBOA, hemorrhagic shock, resuscitation
Christian R Timbol, James N Baraniuk
Open Access Emergency Medicine, Volume 11, pp 15-28; doi:10.2147/oaem.s176843

Abstract:Chronic fatigue syndrome in the emergency department Christian R Timbol,* James N Baraniuk* Division of Rheumatology, Immunology and Allergy, Georgetown University, Washington, DC, USA *Both authors contributed equally to this work Purpose: Chronic fatigue syndrome (CFS) is a debilitating disease characterized by fatigue, postexertional malaise, cognitive dysfunction, sleep disturbances, and widespread pain. A pilot, online survey was used to determine the common presentations of CFS patients in the emergency department (ED) and attitudes about their encounters.Methods: The anonymous survey was created to score the severity of core CFS symptoms, reasons for going to the ED, and Likert scales to grade attitudes and impressions of care. Open text fields were qualitatively categorized to determine common themes about encounters.Results: Fifty-nine percent of respondents with physician-diagnosed CFS (total n=282) had gone to an ED. One-third of ED presentations were consistent with orthostatic intolerance; 42% of participants were dismissed as having psychosomatic complaints. ED staff were not knowledgeable about CFS. Encounters were unfavorable (3.6 on 10-point scale). The remaining 41% of subjects did not go to ED, stating nothing could be done or they would not be taken seriously. CFS subjects can be identified by a CFS questionnaire and the prolonged presence (>6 months) of unremitting fatigue, cognitive, sleep, and postexertional malaise problems.Conclusion: This is the first investigation of the presentation of CFS in the ED and indicates the importance of orthostatic intolerance as the most frequent acute cause for a visit. The self-report CFS questionnaire may be useful as a screening instrument in the ED. Education of ED staff about modern concepts of CFS is necessary to improve patient and staff satisfaction. Guidance is provided for the diagnosis and treatment of CFS in these challenging encounters. Keywords: patient satisfaction, orthostatic intolerance, postexertional malaise, myalgic encephalomyelitis, systemic exertion intolerance disease, SEID
Aleksandr M. Tichter, Grigory Ostrovskiy
Open Access Emergency Medicine, Volume 10, pp 193-200; doi:10.2147/oaem.s178134

Abstract:Emergency department antibiotic use for exacerbations of COPD Aleksandr M Tichter,1 Grigory Ostrovskiy2 1New York Presbyterian Hospital, Columbia University Medical Center, VC-2, New York, NY, USA; 2Department of Medical Education, Weill Cornell Medicine-Qatar, Qatar Foundation – Education City, Doha, Qatar Background: COPD is the third leading cause of death, with acute exacerbations accounting for 1.5 million emergency department (ED) visits annually. Guidelines include recommendations for antibiotic therapy, though evidence for benefit is limited, and little is known about ED prescribing patterns. Our objectives were to determine the rate with which ED patients with acute exacerbations of COPD (AECOPD) are treated with antibiotics, compare the proportions of antibiotic classes prescribed, describe trends of antibiotic treatment, and identify predictors of antibiotic therapy.Patients and methods: This was an analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009–2014. Descriptive statistics were used to summarize the rate of antibiotic therapy and the relative proportions of each antibiotic class prescribed for AECOPD. Logistic regression was used to measure the trend in treatment rate over time and identify the variables associated with antibiotic use.Results: There were an estimated 4.5 million ED visits for AECOPD. Antibiotic treatment occurred at a rate of 39%. Among those treated, macrolides (41%) and quinolones (35%) were prescribed most frequently. Logistic regression did not reveal a trend in antibiotic treatment over time and identified emergent/immediate triage level (OR 2.11, 95% CI 1.09–4.10) and elevated temperature (OR 7.92, 95% CI 2.28–27.50) as being independently associated with antibiotic therapy.Conclusion: Less than half of the ED visits for AECOPD resulted in antibiotic therapy, with no upward trend over time. Fever and triage level were predictive of antibiotic therapy, with macrolides and quinolones constituting the agents most commonly prescribed. Keywords: humans, chronic obstructive pulmonary disease, exacerbation, anti-bacterial agents, cross-sectional studies, trend
Camilla Hansen, Kasper G. Lauridsen, Anders S. Schmidt, Bo Løfgren
Open Access Emergency Medicine, Volume 11, pp 1-8; doi:10.2147/oaem.s183248

Abstract:Decision-making in cardiac arrest: physicians' and nurses' knowledge and views on terminating resuscitation Camilla Hansen,1–3 Kasper G Lauridsen,1–3 Anders S Schmidt,1–3 Bo Løfgren1,2,4,5 1Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; 2Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark; 3Clinical Research Unit, Randers Regional Hospital, Randers, Denmark; 4Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; 5Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark Introduction: Many cardiopulmonary resuscitation (CPR) attempts are unsuccessful and must be terminated. On the contrary, premature termination results in a self-fulfilling prophecy. This study aimed to investigate 1) physicians’ self-assessed competence in terminating CPR, 2) physicians’ and nurses’ knowledge of the European Resuscitation Council guidelines on termination, and 3) single factors leading to termination. Methods: Questionnaires were distributed at advanced cardiac life support (ACLS) courses at a university hospital in Denmark. Participants included ACLS health care providers, ie, physicians and nurses from cardiac arrest teams, intensive care and anesthetic units or medical wards with a duty to provide ACLS. Physicians were divided into junior physicians (house officers) and experienced physicians (specialist registrars and consultants). Results: Overall, 308 participants responded (104 physicians and 204 nurses, response rate: 98%). Among physicians, 37 (36%) did not feel competent to decide when to terminate CPR (junior physicians: n=16, 64%, compared with experienced physicians: n=21, 28%, P=0.002). Two (2%) physicians and one (0.5%) nurse were able to state the contents of termination guidelines. Several factors were reported to impact termination, including absence of a pupillary light reflex (physicians: 17%, nurses: 22%) and cardiac standstill on echocardiography (physicians: 18%, nurses: 20%). Moreover, nine (9%) physicians and 35 (17%) nurses would terminate prolonged CPR despite a shockable rhythm present. Conclusion: One-third of all physicians did not feel competent to decide when to terminate CPR. Physicians’ and nurses’ knowledge of termination guidelines was poor, and both professions reported unvalidated or controversial factors as a single reason for terminating CPR. Keywords: resuscitation, ethics, end-of-life decision, living will, medical decision-making
Tian-Tee Ng
Open Access Emergency Medicine, Volume 10, pp 177-182; doi:10.2147/oaem.s178850

Abstract:Aural foreign body removal: there is no one-size-fits-all method Tian-Tee Ng ENT Unit, Department of Surgery, Frankston Hospital. Peninsula Health, Frankston 3199, VIC, Australia Background: Managing patients with aural foreign body (AFB) may pose a dilemma regarding which removal technique to use for different AFB types. The current study comprises a review of all the possible methods one could employ in removing AFB. My aim was to describe the best methods for different types of AFBs, complete with a description of the method and tool(s) required, and descriptions of the AFBs for which they are best used. Materials and methods: The medical literature published between 2000 and 2016 was reviewed using Medline, Cinahl, Embase, Cochrane, PubMed, and Scopus to compile a list of all published AFB removal methods. Results: Ten methods were identified and described, each having their own advantages for different AFBs. Patients normally permit very few attempts, so the first AFB removal attempt should ideally be the only one. Conclusion: There is no single method guaranteed to work with all AFBs, so this report also contains a flowchart to aid deciding which technique to use. Keywords: foreign body, ear, emergency care
German Devia Jaramillo, Jenny Castro Canoa, Emiro Valverde Galván
Open Access Emergency Medicine, Volume 10, pp 183-191; doi:10.2147/oaem.s177349

Abstract:Approach of minimal invasive monitoring and initial treatment of septic patient in emergency medicine German Devia Jaramillo,1 Jenny Castro Canoa,1 Emiro Valverde Galván2 1Emergency Medicine Department, Hospital Universitario Mayor Méderi Universidad del Rosario, Bogotá, Colombia; 2Emergency Medicine, Universidad del Rosario, Bogotá, Colombia Sepsis and septic shock constitute a complex disease condition that requires the engagement of several medical specialties. A great number of patients with this disease are constantly admitted to the emergency department, which warrants the need for emergency physicians to lead in the recognition and early management of septic patients. Timely and appropriate interventions may help reduce mortality in a disease with an unacceptably high mortality rate. Poor control of cellular hypoperfusion is one of the most influential mechanisms contributing to the high mortality rate in these patients. This article aims to make an evidence-based approach and an algorithm for the active identification of hypoperfusion in patients with suspicion of severe infection, based on both clinical variables (capillary refill, mottling index, left ventricular function by ultrasound, temperature gradient, etc.) and laboratory-measured variables (lactate, central venous oxygen saturation [ScvO2], and venous-to-arterial carbon dioxide tension difference [P (v−a) CO2]). Such variables are feasible to use in the emergency department and would help to explain the cause behind the inadequate oxygen use by cells, thereby guiding treatment at the macrovascular, microvascular, or cellular level. Keywords: sepsis, septic shock, cellular perfusion, microcirculation, emergency medicine
Elizabeth A Brooks, Mark Piehl
Open Access Emergency Medicine, Volume 10, pp 165-170; doi:10.2147/oaem.s175302

Abstract:Potential mortality and cost reduction in adult severe sepsis and septic shock through the use of an innovative fluid delivery device Elizabeth A Brooks,1 Mark Piehl2–4 1Health Economics, TTi Health Research and Economics, Hampstead, MD, USA; 2410 Medical, Durham, NC, USA; 3Pediatric Critical Care, WakeMed Children’s Hospital, Raleigh, NC, USA; 4Department of Pediatrics, University of North Carolina Chapel Hill, Chapel Hill, NC, USA Background: While early fluid resuscitation has been shown to significantly improve health and economic metrics in septic shock, providers are often unable to achieve fluid delivery guidelines using current techniques.Purpose: To examine expected clinical and economic consequences of more consistent achievement of fluid resuscitation guidelines through use of a novel fluid delivery technology.Patients and methods: A decision analytic model was developed to compare expected costs and outcomes associated with the standard technique vs a novel, faster technique for rapid fluid resuscitation in adult patients with severe sepsis or septic shock.Results: Use of an innovative fluid delivery device (LifeFlow) resulted in lower expected mortality compared to standard intravenous fluid delivery methods (reduction of 10 fewer deaths per 500 cases). Compared to standard methods, use of the innovative rapid fluid delivery device also resulted in lower expected hospital costs (US$1,569,131 cost reduction per 500 cases), a lower required use of mechanical ventilation (24% vs 31%), decreased average length of stay (11 vs 13 days), decreased average intensive care unit length of stay (2 vs 3 days), and decreased use of vasopressors (17% vs 21%). A sensitivity analysis showed that utilization of the rapid fluid delivery device is more cost-effective than standard methods, even under the most conservative assumptions.Conclusion: Based on existing data supporting the importance of early, controlled fluid resuscitation in septic shock patients, the analytical model developed in this study demonstrated the benefit of a novel device that facilitates earlier fluid bolus completion and better adherence to sepsis bundles. Keywords: sepsis syndrome, sepsis bundles, fluid administration, surviving sepsis campaign, resuscitation
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