Annals of emergency medicine最新文献

Study objective: The osmol gap can help detect and manage those with toxic alcohol exposure, and it is altered by all alcohols including ethanol. The optimal correction for ethanol that would allow accurate detection of an alternative alcohol is unclear.

Methods: We conducted a prospective cohort study to assess baseline variations in osmol gap, and then to assess the validity of 2 commonly used coefficients (correction factors) for ethanol. Twenty-two healthy volunteers received a body mass-based dose of oral ethanol that targeted an estimated peak blood ethanol concentration >200 mg/dL. We measured laboratory values prior to ethanol administration and at 2, 4, and 6 hours after ingestion. We considered an osmol gap >10 or <-10 abnormal and an osmol gap of >10 after correction as a false positive.

Results: Four of the 22 subjects (18%) had an osmol gap >10 at baseline. Following ethanol ingestion and across 66 timepoints (N=66), there were 14 abnormal osmol gap tests (21%) when corrected with an ethanol coefficient of 4.6, and 31 (47%) abnormal tests when corrected using the Purssell ethanol coefficient of 3.7. The mean difference between the baseline and the post-ethanol corrected osmol gap was lower with the molecular weight correction factor of 4.6 compared with the Purssell correction factor of 3.7 (0.2 versus 11.0; P<.001).

Conclusion: Our data show that the osmol gap is occasionally elevated absent ingestion of any alcohol, and using an ethanol correction coefficient of 4.6 produced a better clinical osmol gap input albeit still with some variation.

Study objective: To cover pediatric emergency physicians' off-hours, third-year pediatric residents in Israel are trained for unsupervised administration of emergency department (ED) dissociative and deep sedation. We assessed the frequency of critical sedation events associated with resident-performed sedations.

Methods: We conducted a retrospective chart review on all patients receiving intravenous sedation across 10 pediatric EDs between January 2018 and September 2022. We defined a critical sedation event as one or more of the following: chest compressions, tracheal intubation, neuromuscular blockers, vasopressors, atropine for bradycardia, aspiration syndrome, death, or unplanned hospital admission due to sedation. We liaised with the Ministry of Health's reporting department and ED directors to verify complete identification of all sentinel events.

Results: Pediatric residents and pediatric emergency physicians performed 12,733 and 10,845 sedations, respectively, most frequently for fracture reduction (44.4%) and laceration repair (25.6%). Patients' mean (SD) age was 6.9 (4.4) years. Residents and emergency physicians administered ketamine or propofol alone in 6,473 and 3,465 cases, respectively, with drug combinations for the remainder. We identified 6 critical sedation events, of which 3 were resident-performed sedations. The frequency of critical sedation events among pediatric residents and emergency physicians was 0.024% (95% CI, 0.005% to 0.069%) and 0.028% (95% CI, 0.006% to 0.080%), respectively.

Conclusion: We observed a low frequency of critical sedation events in this large sample of dissociative and deep sedations performed by pediatric residents and pediatric emergency physicians. Our findings suggest that ED sedation by unsupervised, trained pediatric residents is a safe practice in Israel.

Study objective: Nontraumatic, incidental findings on computed tomography (CT) may be discovered after blunt abdominal trauma in children; however, the rate and importance of these findings are not well known. The objective of this study was to determine the prevalence and types of incidental CT findings among injured children undergoing abdominal/pelvic CT.

Methods: This was a planned secondary analysis of a multicenter prospective cohort study of children (<18 years) who underwent abdominal/pelvic CT after blunt trauma. We abstracted radiology reports for nontraumatic findings. We assessed and classified findings by their clinical urgency.

Results: Of 7,581 children enrolled, 2,500 (33%) underwent abdominal/pelvic CT. The mean patient age was 10.1±4.8 years, and 1,446 (58%) were boys. A total of 988 (39.5%, 95% CI 37.6 to 41.5%) children had 1,552 incidental findings with a mean patient age of 10.6±4.8 years, of whom 59% were boys. Fifty-five (3.5%) incidental findings were considered to need immediate evaluation/treatment, and 84 (5.4%) were considered to require outpatient follow-up within 4 weeks. Most incidental findings, however, were considered less urgent regarding follow-up: 552 (36%) were routine, 574 (37%) were considered to have a potential need, and 287 (18%) did not need follow-up.

Conclusions: Forty percent of children undergoing CT scanning after abdominal trauma have incidental findings, few of which are clinically important and require timely follow-up. CT scans should be obtained only when necessary, and clinicians must be prepared to address incidental findings and ensure proper management.

Study objectives: Concentrated albumin early in sepsis resuscitation remains largely unexplored. Objectives were to determine 1) feasibility of early intervention with concentrated albumin in emergency department (ED) patients with suspected infection and hypoperfusion and 2) whether early albumin therapy improves outcomes.

Methods: ED patients with suspected infection and hypoperfusion (systolic blood pressure [SBP]<90 mmHg or lactate ≥4.0 mmol/L) were randomized to receive either 400 mL 20% albumin over 4 hours or no albumin. All patients were treated with crystalloids, antibiotics, and other therapies at the treating team's discretion. Primary outcome was SBP at 24 hours; secondary outcomes included SBP at 6 hours, fluid and organ support requirements, organ dysfunction, and mortality. Quantile and logistic regressions were used to calculate differences (and 95% CI) between study groups.

Results: Compliance with study protocol was more than 95%, and infection was confirmed in 95% of the 464 study patients enrolled. SBP at 24 hours did not differ between intervention (110.5 mmHg) and standard care arms (110 mmHg). In patients treated with albumin, SBP was higher at 6 hours, less total fluid was infused at 72 hours, fewer patients required vasopressor therapy at 24 and 72 hours, and organ function was improved. Mortality was not significantly different.

Conclusions: Early identification, trial enrollment, and intervention in ED patients with sepsis is feasible. In this pilot study, concentrated albumin given early in resuscitation did not improve SBP at 24 hours. Albumin was associated with less total fluid and vasopressor requirements and improved organ dysfunction. A multicenter study is indicated.