A 20-year-old woman was brought to the hospital in an ambulance after ingesting 18 g of caffeine and 3500 mg of mexiletine 80 min earlier. On arrival at the emergency room, her vital signs were as follows: blood pressure, 65/37 mmHg; heart rate, 140 beats/min; and Glasgow Coma Scale, E4V4M6. Laboratory analyses revealed hypokalemia and lactic acidosis. The patient was treated with mechanical ventilation after intratracheal intubation, intravenous noradrenaline infusion, gastric lavage, and activated charcoal administration. Shortly afterwards, she developed pulseless ventricular tachycardia, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. As the circulatory collapse continued, hemodialysis (HD) was performed with continuous intravenous infusion of noradrenaline. After the completion of HD, the noradrenaline dose was reduced. On hospital day 2, HD was performed on the second day of hospitalization. On hospital days 3 and 4, the patient was weaned off VA-ECMO and ventilator. The blood concentrations of caffeine and mexiletine at presentation were 387 μg/mL and 1.1 μg/mL respectively. During the first HD, blood concentrations of both drugs were markedly reduced. It has been reported that mexiletine may reduce the clearance of caffeine probably via inhibition of N-demethylation. In this case, the endogenous clearance of caffeine, calculated from blood concentrations, was considerably lower than estimated. If HD had not been performed, it may have taken longer to wean off the VA-ECMO because of reduced caffeine clearance in the presence of mexiletine. Notably, caffeine poisoning is more severe and prolonged when mexiletine is administered.
{"title":"Severe caffeine poisoning with mexiletine successfully treated by extracorporeal methods: A case report.","authors":"Saeko Kohara, Yoshito Kamijo, Ryoko Kyan, Tomohiro Yoshizawa, Tatsuaki Takahashi, Kijong Shin, Eiju Hasegawa","doi":"10.1016/j.ajem.2024.09.034","DOIUrl":"https://doi.org/10.1016/j.ajem.2024.09.034","url":null,"abstract":"<p><p>A 20-year-old woman was brought to the hospital in an ambulance after ingesting 18 g of caffeine and 3500 mg of mexiletine 80 min earlier. On arrival at the emergency room, her vital signs were as follows: blood pressure, 65/37 mmHg; heart rate, 140 beats/min; and Glasgow Coma Scale, E4V4M6. Laboratory analyses revealed hypokalemia and lactic acidosis. The patient was treated with mechanical ventilation after intratracheal intubation, intravenous noradrenaline infusion, gastric lavage, and activated charcoal administration. Shortly afterwards, she developed pulseless ventricular tachycardia, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. As the circulatory collapse continued, hemodialysis (HD) was performed with continuous intravenous infusion of noradrenaline. After the completion of HD, the noradrenaline dose was reduced. On hospital day 2, HD was performed on the second day of hospitalization. On hospital days 3 and 4, the patient was weaned off VA-ECMO and ventilator. The blood concentrations of caffeine and mexiletine at presentation were 387 μg/mL and 1.1 μg/mL respectively. During the first HD, blood concentrations of both drugs were markedly reduced. It has been reported that mexiletine may reduce the clearance of caffeine probably via inhibition of N-demethylation. In this case, the endogenous clearance of caffeine, calculated from blood concentrations, was considerably lower than estimated. If HD had not been performed, it may have taken longer to wean off the VA-ECMO because of reduced caffeine clearance in the presence of mexiletine. Notably, caffeine poisoning is more severe and prolonged when mexiletine is administered.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142333045","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-25DOI: 10.1016/j.ajem.2024.09.052
Tai-Jung Chen, Min-Po Ho
{"title":"Shock index pediatric age-adjusted for predicting severe outcomes in patients with pediatric trauma.","authors":"Tai-Jung Chen, Min-Po Ho","doi":"10.1016/j.ajem.2024.09.052","DOIUrl":"https://doi.org/10.1016/j.ajem.2024.09.052","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142333046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-21DOI: 10.1016/j.ajem.2024.09.042
Andrew Farkas MD , Tyler Turner MD , Katherine Sherman MS , Ashley Pavlic MD
Introduction
According to the guidelines of the American Heart Association and American College of Emergency Physicians, respectively, there is no indication for immediate lowering of asymptomatic hypertension in the Emergency Department (ED), and no requirement for routine diagnostic testing in these patients. Despite this, asymptomatic hypertension represents a recurring source of referrals for ED evaluation from other healthcare settings, or from patient self-referral, with significant practice variation in the evaluation and treatment of this complaint.
Methods
This is a pre-post study of a pathway to standardize care of patients presenting to a tertiary academic Veteran's Health Administration ED with asymptomatic hypertension. Inclusion criteria were patients with ICD10 codes of hypertension who were confirmed via chart review to have sought care for a complaint of elevated blood pressure readings from 2018 to 2022, with the pathway having been implementing in 2022. Patients were excluded if they had symptoms of possible end organ pathology due to hypertension, such as chest pain, headache, or shortness of breath, or if they were reproductive age women who had not undergone a sterilization procedure. The primary outcome was major adverse cardiovascular event within 30 days of ED visit. Secondary outcomes included: diagnostic tests performed, administration of antihypertensives in the ED, and length of stay. Descriptive statistics and statistical analysis were performed.
Results
There were a total of 295 unique patients and 324 patient encounters that met the inclusion/exclusion criteria, with 46 encounters that took place after pathway implementation. There were no major adverse cardiovascular events either before or after pathway implementation. Chest radiographs were reduced from 10 % to 0 % (p = 0.005) after pathway respectively. There were also declines in laboratory testing, EKGs, and administration of oral antihypertensives, but these differences were not statistically significant. At no point did any diagnostic testing identify any previously undiagnosed medical conditions. There were no instances of intravenous hypertensives being given after pathway implementation. Despite the reductions in diagnostic testing, there was no change in ED length of stay for patients with asymptomatic hypertension.
Conclusion
Our findings redemonstrate that patients presenting to the ED with asymptomatic hypertension are at low risk for short-term complications of hypertension, and that diagnostic testing is low yield in this population. While we were able to achieve reductions in unnecessary testing, further work is needed to educate clinicians and improve adherence to evidence based principles when caring for these patients.
{"title":"Implementation of a clinical pathway for the evaluation of asymptomatic hypertension in the emergency department","authors":"Andrew Farkas MD , Tyler Turner MD , Katherine Sherman MS , Ashley Pavlic MD","doi":"10.1016/j.ajem.2024.09.042","DOIUrl":"10.1016/j.ajem.2024.09.042","url":null,"abstract":"<div><h3>Introduction</h3><div>According to the guidelines of the American Heart Association and American College of Emergency Physicians, respectively, there is no indication for immediate lowering of asymptomatic hypertension in the Emergency Department (ED), and no requirement for routine diagnostic testing in these patients. Despite this, asymptomatic hypertension represents a recurring source of referrals for ED evaluation from other healthcare settings, or from patient self-referral, with significant practice variation in the evaluation and treatment of this complaint.</div></div><div><h3>Methods</h3><div>This is a pre-post study of a pathway to standardize care of patients presenting to a tertiary academic Veteran's Health Administration ED with asymptomatic hypertension. Inclusion criteria were patients with ICD10 codes of hypertension who were confirmed via chart review to have sought care for a complaint of elevated blood pressure readings from 2018 to 2022, with the pathway having been implementing in 2022. Patients were excluded if they had symptoms of possible end organ pathology due to hypertension, such as chest pain, headache, or shortness of breath, or if they were reproductive age women who had not undergone a sterilization procedure. The primary outcome was major adverse cardiovascular event within 30 days of ED visit. Secondary outcomes included: diagnostic tests performed, administration of antihypertensives in the ED, and length of stay. Descriptive statistics and statistical analysis were performed.</div></div><div><h3>Results</h3><div>There were a total of 295 unique patients and 324 patient encounters that met the inclusion/exclusion criteria, with 46 encounters that took place after pathway implementation. There were no major adverse cardiovascular events either before or after pathway implementation. Chest radiographs were reduced from 10 % to 0 % (<em>p</em> = 0.005) after pathway respectively. There were also declines in laboratory testing, EKGs, and administration of oral antihypertensives, but these differences were not statistically significant. At no point did any diagnostic testing identify any previously undiagnosed medical conditions. There were no instances of intravenous hypertensives being given after pathway implementation. Despite the reductions in diagnostic testing, there was no change in ED length of stay for patients with asymptomatic hypertension.</div></div><div><h3>Conclusion</h3><div>Our findings redemonstrate that patients presenting to the ED with asymptomatic hypertension are at low risk for short-term complications of hypertension, and that diagnostic testing is low yield in this population. While we were able to achieve reductions in unnecessary testing, further work is needed to educate clinicians and improve adherence to evidence based principles when caring for these patients.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"86 ","pages":"Pages 37-40"},"PeriodicalIF":2.7,"publicationDate":"2024-09-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142314211","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-20DOI: 10.1016/j.ajem.2024.09.049
Daniel W. Markwalter MD , Jared Lowe MD , Ming Ding MBBS, ScD , Michelle Lyman MD, MPH , Kyle Lavin MD, MPH
Introduction
80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice.
Methods
We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS).
Results
202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21).
Conclusion
In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.
{"title":"Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program","authors":"Daniel W. Markwalter MD , Jared Lowe MD , Ming Ding MBBS, ScD , Michelle Lyman MD, MPH , Kyle Lavin MD, MPH","doi":"10.1016/j.ajem.2024.09.049","DOIUrl":"10.1016/j.ajem.2024.09.049","url":null,"abstract":"<div><h3>Introduction</h3><div>80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice.</div></div><div><h3>Methods</h3><div>We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS).</div></div><div><h3>Results</h3><div>202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (<em>P</em> = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (<em>P</em> = 0.78). ED LOS was unaffected (<em>P</em> = 0.21).</div></div><div><h3>Conclusion</h3><div>In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"86 ","pages":"Pages 56-61"},"PeriodicalIF":2.7,"publicationDate":"2024-09-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142322196","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-19DOI: 10.1016/j.ajem.2024.09.045
Adhish Gautam, Alexei A Birkun
{"title":"Optimizing emergency dispatcher pre-arrival guidance on first aid for snakebites.","authors":"Adhish Gautam, Alexei A Birkun","doi":"10.1016/j.ajem.2024.09.045","DOIUrl":"https://doi.org/10.1016/j.ajem.2024.09.045","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142333043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Safety and efficacy of a hybrid intravenous and oral diltiazem protocol for acute rate control in the emergency department.","authors":"Jung-Chi Chiang, Chien-Chieh Hsieh, Fu-Shan Jaw, Yin-Chen Yeh, Tang-Sai Tat, Rong-Rong Luo","doi":"10.1016/j.ajem.2024.09.047","DOIUrl":"https://doi.org/10.1016/j.ajem.2024.09.047","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2024-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142333044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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