American Journal of Emergency Medicine最新文献

Objectives: To determine the accuracy of emergency physicians (EPs) in diagnosing pneumoperitoneum with POCUS, and if the volume of pneumoperitoneum affects accuracy.

Methods: POCUS clips were obtained from patients undergoing intraperitoneal insufflation for an elective laparoscopic procedure. Video clips of the right upper quadrant and epigastric regions were obtained prior to insufflation and then after 500 ml, 1000 ml, and 1500 ml of insufflation. These clips were randomized and reviewed by three blinded ultrasound-trained EPs. For each clip they determined whether pneumoperitoneum was present or not.

Results: EPs chose correctly 71 % of the time. Overall sensitivity for detecting pneumoperitoneum was 66 % with a specificity of 85 %. Sensitivity for detecting small, medium, and large volumes of air was 53 %, 70 %, and 73 % respectively. The AUC for pneumoperitoneum overall was 0.753. The AUC for detecting small, medium, and large volumes of air was 0.688, 0.773, and 0.789 respectively. There was substantial agreement between EPs with a kappa of 0.658.

Conclusions: POCUS for pneumoperitoneum had moderate sensitivity, high specificity and moderate accuracy. The sensitivities increased with increasing volumes of air. This data suggests that POCUS has similar sensitivity to CXR for pneumoperitoneum.

Objectives: The recommended epinephrine administration interval during CPR is between 3 and 5 min. However, the optimal interval for improving cerebral perfusion remains controversial. This study aimed to evaluate the effects of epinephrine administration interval of 3 min or 5 min on cerebral perfusion pressure (CEPP) and cortical cerebral blood flow (CCBF) in a porcine cardiac arrest model.

Methods: An experimental model of ventricular fibrillation (VF) cardiac arrest was conducted using 26 pigs, randomised into 3-min and 5-min interval groups. Six minutes after VF induction, all pigs received 4 min of chest compressions, followed by 20 min of advanced cardiovascular life support, including defibrillation and intravenous epinephrine administration. CEPP and CCBF were measured simultaneously throughout the experiment.

Results: Each of the experimental groups comprised 13 pigs. The 3-min group showed higher CEPP compared with the 5-min group in between 16 min and 20 min, 26 min and 30 min from VF induction: mean (95 % Confidence intervals) 26.8 (4.7-49.0) mmHg for 3-min group and 11.3 (-5.7-28.3) mmHg for 5-min group in 18 to 20 min from VF induction, which showed biggest difference. No significant difference was observed in CCBF between the 3-min and 5-min groups throughout the resuscitation phase (from the first epinephrine administration): The relative ratios 6 to 8 min after VF induction ranged from 0.21 to 0.86 in the 3-min group, and 0.35 to 0.77 in the 5-min group.

Conclusion: The 3-min epinephrine administration interval showed a higher CEPP compared with the 5-min interval. No significant differences were found in the CCBF between the two interval groups.

Introduction: We investigated the extent to which demographic characteristics, clinical care aspects, and relevant biomarkers predicted sepsis-related mortality among patients transferred from a rural, low-volume emergency department (ED) to an urban, high-volume, level-2 trauma center.

Methods: We conducted an observational study among adult severe sepsis patients (N = 242) who, within a community-based regional healthcare system, presented to one of the four rural, low-volume EDs and were subsequently transferred to the urban, high-volume, level-2 trauma center, and were identified as septic at either location. We evaluated in-hospital and 30 days after discharge mortality.

Results: In-hospital mortality rate was predicted by previous admission to an ICU (OR 5.02, 95 % CI: 1.89-15.94, p = 0.002), identification of sepsis prior to transfer (OR 0.29, 95 % CI: 0.11-0.74, p = 0.01), and a moderately abnormal lactate level (OR 0.22, 95 % CI: 0.05-0.79, p = 0.03). Mortality 30 days after discharge was predicted by previous admission to an ICU (OR: 3.28, 95 % CI: 1.62-6.97, p = 0.001), abnormal red cell distribution width (OR: 2.23, 95 % CI: 1.11-4.60, p = 0.03), identification of sepsis prior to transfer (OR: 0.26, 95 % CI: 0.12-0.54, p < 0.001), and a moderately abnormal lactate (OR: 0.32, 95 % CI: 0.12-0.79, p = 0.02).

Discussion: Early identification of sepsis, as well as attention to prior ICU admission or comorbidities and abnormal red cell distribution width, could facilitate better care and prevent mortality among patients with sepsis who are transferred from a rural, low-volume emergency department to an urban-high volume facility.

Background: Mass Casualty Events (MCI) which have a direct and persisting impact on the safety and well-being of an emergency department (ED) and its staff, secondary to specific targeting of the healthcare setting, represent a distinct and complex operational challenge. ED physicians may be faced with the prospect of providing ongoing patient care while simultaneously experiencing direct threats to their own health or physical safety. In our study we considered the unique operational challenges encountered, and management strategies adopted, by the ED staff and its leadership to an all-hazard MCI impacting an academic urban emergency department.

Methods: We conducted a retrospective, observational study of data from a tertiary academic medical center of patients arriving to the ED during a protracted MCI lasting from May 11th to May 21st, 2021. No arriving patients were excluded from analysis. Patient demographics, ED resource utilization, throughput, disposition and other pertinent data were considered. Analysis was done of three distinct patient populations including the event-group (EG), a non-event-group (NEG) and a control group (CG). Descriptive statistics were used to evaluating observational findings.

Results: We reviewed the records of 8527 total patients presenting to the Shamir Medical Center ED during the event and control periods. Of those, 283 patients were identified as an EG consisting of casualties from the MCI. 3563 patients were identified as the NEG presenting with complaints not related to the event. Our CG consisted of the 4681 patients who presented in the two weeks prior to the MCI. EG patients were noted to have important characteristics including higher relative numbers of men n = 173 (61.6 %), higher CTAS triage acuities [n = 10 (3.8 %), classified as CTAS 1], and an increase utilization of specialty consultation and admission consistent with observed injury patterns, most notably for the orthopedic services [orthopedic consultations: n = 126 (44.5 %) / orthopedic admissions: n = 13 (4.6 %)].

Conclusion: Findings from our observational study suggested that in the absence of larger public health interventions a manmade MCI, with direct threats to an ED and its staff, could force EDs to concurrently address the unique clinical needs of two distinct patient populations while simultaneously needing to take measures to protect hospital staff. Additionally, a higher burden of patient volumes and clinical acuity are likely to be encountered by select specialty consultation services. Further studies could focus on quantitative analysis to better understand the operational impact of these types of events on both patients and staff.

Bacterial meningitis is an increasingly rare disease that carries significant morbidity and mortality. We describe the case of a 38-year-old male with a past medical history of pituitary macroadenoma with prior endonasal surgeries on prednisone therapy daily for resultant hypopituitarism and juvenile myoclonic epilepsy on lamotrigine daily who was transferred to an academic tertiary emergency department due to concern for developing pituitary apoplexy. At the outside emergency department, the patient presented complaining of sudden onset severe headache. CT scan demonstrated residual pituitary mass but no additional findings. On arrival to our emergency department, the patient was altered and newly febrile. Physical exam was notable for the patient moving all extremities and opening eyes spontaneously but unable to follow commands with a positive Kernig's sign. Broad spectrum antibiotics, antivirals, and stress dosed steroids were started due to concern for meningitis, and Neurology and Neurosurgery were consulted. Repeat CT was obtained prior to lumbar puncture (LP). LP demonstrated bacterial meningitis, which later speciated to Streptococcus salivarius. The patient was admitted to the medical ICU and discharged with full neurologic recovery on hospital day 13. This case demonstrates the variable presentation of bacterial meningitis as the patient was not initially febrile or altered. Emergency physicians index of suspicion for meningitis should be increased with risk factors such as immunosuppression and history of transsphenoidal surgery, as in our patient. Our case is a unique case of Streptococcus salivarius meningitis that has been previously associated with primarily iatrogenic etiologies.