Assuntos
Serviço Hospitalar de Emergência , Sugammadex , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , AdultoRESUMO
PresentationAn 83-year-old man presented for headache and altered mental status. Four days prior, he underwent endoscopic sinus surgery for nasal polyps. Over the two previous days, he gradually developed a headache and was brought to the emergency department when his wife noted mild confusion and generalised weakness. His examination was notable for a heart rate of 101 beats per minute, clear nasal discharge, meningismus and confusion to the date with generalised weakness. A lumbar puncture revealed cloudy cerebrospinal fluid (CSF) with a white blood cell count of 3519x10Ë9/L (95% neutrophils). A CT scan of the head was obtained (figure 1).emermed;38/7/519/F1F1F1Figure 1Non-contrast CT scan of the head in axial plane. QUESTION: What is the appropriate next step in management?Obtain MRI of the brain to localise ischaemic damage.Administer broad-spectrum antibiotics, including pseudomonal coverage.Consult otolaryngology to arrange functional endoscopic sinus surgery for CSF leak closure.Consult neurosurgery for surgical decompression of mass lesion(s).
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Transtornos da Consciência/etiologia , Infecções por Pseudomonas/diagnóstico , Idoso de 80 Anos ou mais , Estudos de Coortes , Cefaleia/etiologia , Humanos , Masculino , Infecções por Pseudomonas/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation. OBJECTIVE: The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport. METHODS: We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups. RESULTS: L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports. CONCLUSIONS: The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.
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Ambulâncias , Cuidados Críticos , Humanos , Estudos Retrospectivos , Fatores de Tempo , Transporte de PacientesRESUMO
Muscle atrophy and cachexia are common comorbidities among patients suffering from cancer, chronic obstructive pulmonary disease, and several other chronic diseases. The peptide hormone ghrelin exerts pleiotropic effects including the stimulation of growth hormone secretion and subsequent increase of insulin-like growth factor-1 levels, an important mediator of muscle growth and repair. Ghrelin also acts on inflammation, appetite, and adipogenesis and therefore has been considered a promising therapeutic target for catabolic conditions. We previously reported on the synthesis and properties of an indane based series of ghrelin receptor full agonists which led to a sustained increase of insulin-like growth factor-1 in a dog pharmacodynamic study. Herein we report on the identification of a series of pyrrolidine or piperidine based full agonists and attempted optimization to give compounds with profiles suitable for progression as clinical candidates.
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Desenho de Fármacos , Pirrolidinas/química , Pirrolidinas/farmacologia , Receptores de Grelina/agonistas , Animais , Cães , Células HEK293 , Humanos , Pirrolidinas/farmacocinética , RatosAssuntos
Colonoscopia , Endoscopia do Sistema Digestório , Hemorragia Pós-Operatória/diagnóstico por imagem , Esplenopatias/diagnóstico por imagem , Dor Abdominal/etiologia , Idoso , Dor no Peito/etiologia , Feminino , Humanos , Hemorragia Pós-Operatória/complicações , Esplenopatias/complicações , Tomografia Computadorizada por Raios XRESUMO
Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.
Assuntos
Asma/fisiopatologia , Pressão Sanguínea/fisiologia , Ecocardiografia Doppler/instrumentação , Ecocardiografia Doppler/métodos , Coração/fisiopatologia , Sistemas Automatizados de Assistência Junto ao Leito , Adolescente , Criança , Pré-Escolar , Feminino , Coração/diagnóstico por imagem , Humanos , Masculino , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment. METHODS: Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6-hour time periods during the first 48 hours of AC were collected and analyzed. RESULTS: A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values. CONCLUSIONS: The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.
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Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Tempo de Tromboplastina Parcial/estatística & dados numéricos , Embolia Pulmonar/tratamento farmacológico , Doença Aguda , Adulto , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: It is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72â¯h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. OBJECTIVE: This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. METHODS: Retrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14â¯days requiring ICU admission. RESULTS: From 1,106,606 ED visits, 511 patients returned within 14â¯days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. CONCLUSION: Reviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.
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Erros de Diagnóstico , Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Readmissão do Paciente/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoAssuntos
Transtornos da Consciência/etiologia , Hipoglicemia/diagnóstico , Hipotensão/etiologia , Recidiva , Transtornos da Consciência/psicologia , Serviço Hospitalar de Emergência/organização & administração , Humanos , Hipoglicemia/complicações , Hipoglicemia/fisiopatologia , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-IdadeAssuntos
Faringite/etiologia , Cálculos das Glândulas Salivares/diagnóstico , Feminino , Humanos , Linfonodos/anormalidades , Linfonodos/fisiopatologia , Pessoa de Meia-Idade , Cálculos das Glândulas Salivares/complicações , Sialadenite/complicações , Sialadenite/diagnóstico , Tomografia Computadorizada por Raios X/métodosRESUMO
OBJECTIVES: We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. METHODS: We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. RESULTS: Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. CONCLUSIONS: We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.