Pub Date : 2024-05-08DOI: 10.1016/j.jemermed.2024.05.007
Background
Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications.
Clinical Question
Is phenobarbital an effective treatment for AWS?
Evidence Review
Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS.
Conclusions
Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.
{"title":"Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?","authors":"","doi":"10.1016/j.jemermed.2024.05.007","DOIUrl":"10.1016/j.jemermed.2024.05.007","url":null,"abstract":"<div><h3>Background</h3><p>Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications.</p></div><div><h3>Clinical Question</h3><p>Is phenobarbital an effective treatment for AWS?</p></div><div><h3>Evidence Review</h3><p>Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS.</p></div><div><h3>Conclusions</h3><p>Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141042711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-03DOI: 10.1016/j.jemermed.2024.04.005
Background
Exertional heat illnesses (EHIs), specifically exertional heat stroke (EHS), are a top cause of nonaccidental death among U.S. laborers. EHS management requires coordination between Emergency Medical Services (EMS) and workplace officials to implement cold water immersion (CWI) and cool first, transport second (CFTS).
Objective
The purpose of this article was to quantify and identify existing statewide EMS guidelines, determine whether statewide EHS guidelines improved outcomes for EHIs in laborers, and examine the odds of laborer EHS fatalities when best practices are present in EMS statewide guidelines.
Methods
The Paramedic Protocol Provider database and official EMS websites were examined to determine which U.S. states had statewide EMS guidelines and, for those with statewide guidelines, a two-way χ2 analysis with associated odds ratios examined EHI outcomes. Statewide EMS guidelines underwent content analysis by three independent reviewers regarding EHS best practices. Significance was set a priori at p < 0.05.
Results
Among 50 states, the District of Columbia, and Puerto Rico, 57.7% (n = 30) had statewide EMS guidelines and 42.3% (n = 22) did not. There was a significant association for EHI outcome for states recommending CWI as a cooling method vs. those that did not (χ21 = 3.336; p = 0.049). The odds of EHS deaths for laborers were 3.0 times higher if CWI was not included in the EMS guidelines. There was a significant association in EHI outcomes for states without CFTS (χ21 = 5.051; p = 0.017). The odds of laborers dying from EHS were 3.7 times higher in states without CFTS.
Conclusions
Laborers are 3.0 and 3.7 times less likely to die from EHS when statewide EMS guidelines include CWI and CFTS, respectively.
{"title":"Exertional Heat Stroke Best Practices in U.S. Emergency Medical Services Guidelines","authors":"","doi":"10.1016/j.jemermed.2024.04.005","DOIUrl":"10.1016/j.jemermed.2024.04.005","url":null,"abstract":"<div><h3>Background</h3><p>Exertional heat illnesses (EHIs), specifically exertional heat stroke (EHS), are a top cause of nonaccidental death among U.S. laborers. EHS management requires coordination between Emergency Medical Services (EMS) and workplace officials to implement cold water immersion (CWI) and cool first, transport second (CFTS).</p></div><div><h3>Objective</h3><p>The purpose of this article was to quantify and identify existing statewide EMS guidelines, determine whether statewide EHS guidelines improved outcomes for EHIs in laborers, and examine the odds of laborer EHS fatalities when best practices are present in EMS statewide guidelines.</p></div><div><h3>Methods</h3><p>The Paramedic Protocol Provider database and official EMS websites were examined to determine which U.S. states had statewide EMS guidelines and, for those with statewide guidelines, a two-way χ<sup>2</sup> analysis with associated odds ratios examined EHI outcomes. Statewide EMS guidelines underwent content analysis by three independent reviewers regarding EHS best practices. Significance was set <em>a priori</em> at <em>p</em> < 0.05.</p></div><div><h3>Results</h3><p>Among 50 states, the District of Columbia, and Puerto Rico, 57.7% (n = 30) had statewide EMS guidelines and 42.3% (n = 22) did not. There was a significant association for EHI outcome for states recommending CWI as a cooling method vs. those that did not (χ<sup>2</sup><sub>1</sub> = 3.336; <em>p</em> = 0.049). The odds of EHS deaths for laborers were 3.0 times higher if CWI was not included in the EMS guidelines. There was a significant association in EHI outcomes for states without CFTS (χ<sup>2</sup><sub>1</sub> = 5.051; <em>p</em> = 0.017). The odds of laborers dying from EHS were 3.7 times higher in states without CFTS.</p></div><div><h3>Conclusions</h3><p>Laborers are 3.0 and 3.7 times less likely to die from EHS when statewide EMS guidelines include CWI and CFTS, respectively.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141030443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-03DOI: 10.1016/j.jemermed.2024.04.006
Background
Hypertensive crisis is an acute increase in blood pressure >180/120 mm Hg. A titratable antihypertensive agent is preferred to lower blood pressure acutely in a controlled way and prevent an abrupt overcorrection. Nicardipine and clevidipine are both dihydropyridine calcium channel blockers that provide unique benefits for blood pressure control.
Objective
The purpose of this study was to compare the efficacy and safety of nicardipine or clevidipine for blood pressure control in the setting of hypertensive crisis.
Methods
This was a single-center, retrospective cohort study. Eligible patients received either nicardipine or clevidipine for the treatment of hypertensive crisis. The primary outcome was achievement of 25% reduction in mean arterial pressure at 1 h. The secondary outcome was achievement of a systolic blood pressure (SBP) of <160 mm Hg at 2–6 h from the start of the infusion.
Results
This study included a total of 156 patients, 74 in the nicardipine group and 82 in the clevidipine group. The SBP on admission and at the start of the infusion were similar between groups. There was no difference between groups in achieving a 25% reduction in mean arterial pressure at 1 h. Nicardipine achieved an SBP goal of <160 mm Hg at 2–6 h significantly more often than the clevidipine group (89.2% vs. 73.2%; p = 0.011).
Conclusions
There is no difference between agents for initial blood pressure control in the treatment of hypertensive crisis. Nicardipine showed more sustained SBP control, with a lower risk of rebound hypertension and a significant cost savings compared with clevidipine.
{"title":"Evaluation of the Efficacy and Safety of Nicardipine Versus Clevidipine for Blood Pressure Control in Hypertensive Crisis","authors":"","doi":"10.1016/j.jemermed.2024.04.006","DOIUrl":"10.1016/j.jemermed.2024.04.006","url":null,"abstract":"<div><h3>Background</h3><p>Hypertensive crisis is an acute increase in blood pressure >180/120 mm Hg. A titratable antihypertensive agent is preferred to lower blood pressure acutely in a controlled way and prevent an abrupt overcorrection. Nicardipine and clevidipine are both dihydropyridine calcium channel blockers that provide unique benefits for blood pressure control.</p></div><div><h3>Objective</h3><p>The purpose of this study was to compare the efficacy and safety of nicardipine or clevidipine for blood pressure control in the setting of hypertensive crisis.</p></div><div><h3>Methods</h3><p>This was a single-center, retrospective cohort study. Eligible patients received either nicardipine or clevidipine for the treatment of hypertensive crisis. The primary outcome was achievement of 25% reduction in mean arterial pressure at 1 h. The secondary outcome was achievement of a systolic blood pressure (SBP) of <160 mm Hg at 2–6 h from the start of the infusion.</p></div><div><h3>Results</h3><p>This study included a total of 156 patients, 74 in the nicardipine group and 82 in the clevidipine group. The SBP on admission and at the start of the infusion were similar between groups. There was no difference between groups in achieving a 25% reduction in mean arterial pressure at 1 h. Nicardipine achieved an SBP goal of <160 mm Hg at 2–6 h significantly more often than the clevidipine group (89.2% vs. 73.2%; <em>p</em> = 0.011).</p></div><div><h3>Conclusions</h3><p>There is no difference between agents for initial blood pressure control in the treatment of hypertensive crisis. Nicardipine showed more sustained SBP control, with a lower risk of rebound hypertension and a significant cost savings compared with clevidipine.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141023620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-03DOI: 10.1016/j.jemermed.2024.04.007
Background
Parenteral ketorolac and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness.
Study Objectives
To evaluate the comparative effectiveness of IV acetaminophen and parenteral ketorolac for analgesia in the prehospital setting.
Methods
We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain.
Results
Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was −1.9 (SD 2.4) for acetaminophen group and −2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] −0.16, 0.37; PSM: 0.15, 95% CI −0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI −0.35, 0.72; IPTW: 0.23, 95% CI −0.25, 0.71; PSM: −0.03, 95% CI −0.61, 0.54).
Conclusions
We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.
研究目的 评估院前镇痛中静脉注射对乙酰氨基酚和肠外酮咯酸的比较效果。方法 我们对 2019 年 1 月 1 日至 2021 年 11 月 30 日期间郊区大型急救系统中接受静脉注射对乙酰氨基酚或肠外酮咯酸治疗的患者进行了回顾性横断面评估。主要结果是首次到最后一次疼痛评分的变化。对有创伤性疼痛的患者进行了分组分析。我们使用逆概率治疗加权(IPTW)和倾向得分匹配(PSM)估算了对乙酰氨基酚与酮咯酸在所有患者和外伤性疼痛患者亚组中的治疗效果。结果 在纳入的 2178 名患者中,856 人(39.3%)接受了静脉对乙酰氨基酚治疗,1322 人(60.7%)接受了肠外酮咯酸治疗。对乙酰氨基酚组未经调整的疼痛评分平均变化为-1.9(标清2.4)分,酮咯酸组为-2.4(标清2.4)分。在倾向评分分析中,对乙酰氨基酚组与酮咯酸组的疼痛评分变化在所有患者中(平均差异,IPTW:0.11,95% 置信区间 [CI]-0.16,0.37;PSM:0.15,95% CI -0.13,0.43)和外伤性疼痛患者中(未调整:0.18,95% CI -0.35,0.72;IPTW:0.23,95% CI -0.25,0.71;PSM:-0.03,95% CI -0.35,0.72)无统计学显著差异:-结论我们发现,静脉注射对乙酰氨基酚和肠外注射酮咯酸治疗急性疼痛的平均镇痛效果在统计学上没有显著差异。
{"title":"Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review","authors":"","doi":"10.1016/j.jemermed.2024.04.007","DOIUrl":"10.1016/j.jemermed.2024.04.007","url":null,"abstract":"<div><h3>Background</h3><p>Parenteral ketorolac<span> and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness.</span></p></div><div><h3>Study Objectives</h3><p>To evaluate the comparative effectiveness of IV acetaminophen<span> and parenteral ketorolac for analgesia in the prehospital setting.</span></p></div><div><h3>Methods</h3><p>We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain.</p></div><div><h3>Results</h3><p>Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was −1.9 (SD 2.4) for acetaminophen group and −2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] −0.16, 0.37; PSM: 0.15, 95% CI −0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI −0.35, 0.72; IPTW: 0.23, 95% CI −0.25, 0.71; PSM: −0.03, 95% CI −0.61, 0.54).</p></div><div><h3>Conclusions</h3><p>We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141029030","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-03DOI: 10.1016/j.jemermed.2024.04.010
{"title":"A late career crisis in emergency medicine","authors":"","doi":"10.1016/j.jemermed.2024.04.010","DOIUrl":"10.1016/j.jemermed.2024.04.010","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924001380/pdfft?md5=608e5374541db36d94a62e83ea9f0c95&pid=1-s2.0-S0736467924001380-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141050279","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2023.11.014
Zachary Boivin MD , Zhayna Spooner MD , Christina Jiang MS , Kirstin Acus MD , Christina Lu MD , Trent She MD
Background: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.
Case Report: An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.
Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.
{"title":"Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit","authors":"Zachary Boivin MD , Zhayna Spooner MD , Christina Jiang MS , Kirstin Acus MD , Christina Lu MD , Trent She MD","doi":"10.1016/j.jemermed.2023.11.014","DOIUrl":"10.1016/j.jemermed.2023.11.014","url":null,"abstract":"<div><p><em><strong>Background</strong></em>: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.</p><p><strong><em>Case Report:</em></strong> An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.</p><p><strong><em>Why Should an Emergency Physician Be Aware of This?</em></strong> Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138569542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury.
Objective
This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall–related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages.
Methods
We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall–related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1–3), vulnerable-frail (CFS score 4–6), and severely frail (CFS score 7–9).
Results
A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4–16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44–3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41–13.6; p = 0.34) in those considered severely frail.
Conclusions
This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.
背景轻度创伤性脑损伤(TBI)在老年人中发病率很高,而地面跌落是最常见的致伤机制。目的本研究旨在评估在遭受地面跌落相关轻度创伤性脑损伤的老年患者中,虚弱程度是否与头部撞击位置有关。方法我们在两所城市大学附属急诊科(ED)进行了一项前瞻性观察研究的计划子分析。2019年1月至2019年6月期间在急诊科就诊的年龄≥65岁、与地面坠落相关的轻度创伤性脑损伤患者均被纳入研究范围。体弱程度采用临床体弱量表进行评估。患者被分为三组:1-3组(强壮)、4-6组(脆弱-虚弱)和7-9组(严重虚弱)。结果共纳入335名患者,平均年龄为(86.9±8.1)岁。在多变量分析中,与体格健壮的患者相比,严重虚弱患者的额部冲击力明显增加(OR:4.8 [95%CI:1.4-16.8],P=0.01)。在体格健壮、脆弱虚弱和严重虚弱的患者中,分别有 6.2%、7.5% 和 13.3% 出现颅内出血。易受影响的虚弱患者颅内出血的 OR 值为 1.24(95IC%:0.44-3.45,P=0.68),被视为严重虚弱的患者颅内出血的 OR 值为 2.34(95IC%:0.41-13.6,P=0.34)。我们的研究结果表明,跌倒后头部撞击位置可帮助医生识别体弱患者。尽管没有统计学意义,但颅内出血的发生率似乎随着虚弱程度的增加而增加。
{"title":"Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults","authors":"Xavier Dubucs MD, MSC , Éric Mercier MD, MSC , Valérie Boucher MSC , Samuel Lauzon , Frederic Balen MD , Sandrine Charpentier MD, PHD , Marcel Emond MD, MSC","doi":"10.1016/j.jemermed.2024.01.005","DOIUrl":"10.1016/j.jemermed.2024.01.005","url":null,"abstract":"<div><h3>Background</h3><p>Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury.</p></div><div><h3>Objective</h3><p>This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall–related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages.</p></div><div><h3>Methods</h3><p>We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall–related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1–3), vulnerable-frail (CFS score 4–6), and severely frail (CFS score 7–9).</p></div><div><h3>Results</h3><p>A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4–16.8]; <em>p</em> = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44–3.45; <em>p</em> = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41–13.6; <em>p</em> = 0.34) in those considered severely frail.</p></div><div><h3>Conclusions</h3><p>This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924000076/pdfft?md5=5537b8c00800181d98729b35d0f0d7d4&pid=1-s2.0-S0736467924000076-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139509034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.03.017
Christopher Karousatos MD, Lauren Murphy MD
Background
Anticholinergic toxicity is commonly encountered in the emergency department. However, the availability of physostigmine, a central acetylcholinesterase inhibitor used to reverse anticholinergic delirium, has been significantly limited due to national drug shortages in the United States. Several articles have explored the viability of rivastigmine as an alternative treatment in these patients.
Case Report
A 33-year-old man presented to the emergency department after a suspected suicide attempt. The patient was found with an empty bottle of diphenhydramine at the scene. On arrival, he was tachycardic and delirious, with dilated and nonreactive pupils and dry skin. As the clinical picture was highly suggestive of anticholinergic toxicity, the patient was treated with oral rivastigmine at a starting dose of 4.5 mg to reverse his anticholinergic delirium. Although a repeat dose was required, his delirium resolved without recurrence. Why Should an Emergency Physician Be Aware of This? Oral rivastigmine has been applied successfully here and in other case reports to reverse anticholinergic delirium with the benefit of prolonged agitation control. Emergency physicians may consider this medication in consultation with a specialist, with initial doses starting at 4.5–6 mg, if encountering anticholinergic delirium when physostigmine is not available.
{"title":"Treatment of Anticholinergic Delirium with Oral Rivastigmine: A Case Report","authors":"Christopher Karousatos MD, Lauren Murphy MD","doi":"10.1016/j.jemermed.2024.03.017","DOIUrl":"10.1016/j.jemermed.2024.03.017","url":null,"abstract":"<div><h3>Background</h3><p>Anticholinergic toxicity is commonly encountered in the emergency department. However, the availability of physostigmine, a central acetylcholinesterase inhibitor used to reverse anticholinergic delirium, has been significantly limited due to national drug shortages in the United States. Several articles have explored the viability of rivastigmine as an alternative treatment in these patients.</p></div><div><h3>Case Report</h3><p>A 33-year-old man presented to the emergency department after a suspected suicide attempt. The patient was found with an empty bottle of diphenhydramine at the scene. On arrival, he was tachycardic and delirious, with dilated and nonreactive pupils and dry skin. As the clinical picture was highly suggestive of anticholinergic toxicity, the patient was treated with oral rivastigmine at a starting dose of 4.5 mg to reverse his anticholinergic delirium. Although a repeat dose was required, his delirium resolved without recurrence. Why Should an Emergency Physician Be Aware of This? Oral rivastigmine has been applied successfully here and in other case reports to reverse anticholinergic delirium with the benefit of prolonged agitation control. Emergency physicians may consider this medication in consultation with a specialist, with initial doses starting at 4.5–6 mg, if encountering anticholinergic delirium when physostigmine is not available.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140273468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.01.004
Amye Farag MD, Sean Patrick Nordt MDPharmD, Joshua Perese MD
Background
Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum.
Case Report
A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge.
Why Should an Emergency Physician Be Aware of This?
Rectal administration of methamphetamine is known as “plugging,” “booty bumping,” “keestering,” and “butt whacking.” The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.
{"title":"Methamphetamine Poisoning After \"Plugging\" Intentional Recreational Rectal Use","authors":"Amye Farag MD, Sean Patrick Nordt MDPharmD, Joshua Perese MD","doi":"10.1016/j.jemermed.2024.01.004","DOIUrl":"10.1016/j.jemermed.2024.01.004","url":null,"abstract":"<div><h3>Background</h3><p>Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum.</p></div><div><h3>Case Report</h3><p>A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>Rectal administration of methamphetamine is known as “plugging,” “booty bumping,” “keestering,” and “butt whacking.” The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139458274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}