Massive bee envenomation treated by therapeutic plasma exchange.

In the unfortunate event of massive envenomation and precipitation of multiorgan failure, therapeutic plasma exchange (TPE) can be considered as a modality for therapy. We present a patient case where TPE potentially allowed for removal of toxin with subsequent clinical improvement.

Multiple criteria decision analysis approach to consider therapeutic innovations in the emergency department: The methoxyflurane organizational impact in acute trauma pain.

BACKGROUND: Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management. METHODS: We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation's impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact). RESULTS: Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion. CONCLUSIONS: Our model highlighted the putative positive organizational impact of methoxyflurane in the ED-particularly when supported by a trauma care pathway-and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine.

Acute direct traumatic optic neuropathy treated with steroids, minocycline and hyperbaric oxygen: a case report.

We describe the emergency management of a man who experienced acute vision loss diagnosed as direct traumatic optic neuropathy (TON) in his right eye (no light perception) after falling from a height. TON is caused by a high-impact mechanism of injury. Clinical findings include acute vision loss, which is typically immediate, afferent pupillary defect, decreased color vision, and visual field defects. Treatment is controversial because of the lack of strong evidence supporting intervention over observation. In this case report, our treatment strategy comprised immediate hyperbaric oxygen (HBO2) and daily high doses of a steroid. On the second day, minocycline was added to the treatment regimen for its neuroprotective effects. The patient was discharged after receiving six HBO2 treatments and six days of intravenous solumedrol transitioned to oral prednisone. After the third HBO2 treatment, his vision improved to 20/100; after the fourth treatment, it was 20/40 and plateaued. At the time of discharge, it was 20/40. At two-month follow-up, his corrected visual acuity was 20/60+2 in the affected eye. Immediate HBO2 for ischemic and mechanical injury to the optic nerve following trauma is a therapeutic option.

Emergency management of calcium channel blocker overdose.

Calcium channel blockers (CCBs) are commonly used in South Africa (SA) in the management of hypertension and other cardiovascular disease. Their ubiquitous availability makes them a common agent in drug overdose (OD), whether through accidental ingestion or deliberate self-harm. It is essential that medical practitioners know how to recognise and manage CCB OD, as severe CCB OD is often fatal. As there is a lack of local literature in SA, we highlight the general principles of management of CCB OD, as well as complications and problems that may be encountered during treatment. This narrative review is based on existing clinical guidelines, retrospective studies and systematic reviews on the emergency management of CCB OD. High-dose insulin euglycaemic therapy has become the mainstay of treatment in severe CCB OD. The rationale, the recommended protocol for its use and its adverse effects are described.

Effects of First High-Dose Atorvastatin Loading in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

To determine the effects of 80-mg atorvastatin administration for the first time in patients with acute ST segment elevation myocardial infarction (STEMI) before emergency percutaneous coronary intervention (PCI). A total of 118 patients with STEMI who underwent emergency PCI were enrolled in this study. The patients were divided into 80-mg group (n = 59) and 40-mg group (n = 59), according to the loading dose of atorvastatin firstly before operation. The occurrence of no-reflows and changes of HbA1c were observed preoperatively and postoperatively on second and fifth days. All patients were followed up for 1 year with major adverse cardiac events (MACE) recorded. The incidence of no-reflow in 80-mg group was obviously lower than in 40-mg group (13.56% vs. 25.42%) (χ = 4.374, P = 4.374). The preoperative HbA1c levels exhibited no significant difference between 80-mg group and 40-mg group (P > 0.05). The postoperative HbA1c levels in 2 groups showed a trend of gradual decline, which were lower in 80-mg group than in 40-mg group for second day, fifth day, first month, sixth month, and 12th month (all P < 0.05). The postoperative incidence of MACE in 80-mg group was significantly lower than in 40-mg group for sixth and 12th months (both P < 0.05). The incidence of MACE in patients with reflow in 80-mg and 40-mg groups was significantly higher than in patients with no-reflow who were in 80-mg and 40-mg groups for postoperative 12th month (both P < 0.05). The first loading high dose of atorvastatin can significantly prevent occurrence of postoperative no-reflow in patients with STEMI after PCI, reduce HbA1c levels and the incidence of MACE. Clinical randomized controlled trial with larger sample size is required to confirm this finding.

Emergency Department Treatment of Cannabinoid Hyperemesis Syndrome: A Review.

BACKGROUND: Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with chronic cannabis use. As cannabis consumption steadily increases each year, CHS is becoming a commonplace and costly occurrence in hospitals nationwide. Currently, there are no best treatment strategies agreed upon universally. AREAS OF UNCERTAINTY: Thus far, most data about CHS have come from case reports and case series. Consequently, the pathophysiology of the syndrome is unclear, and its occurrence in some cannabis users, but not others, is not understood. DATA SOURCES: A literature search was conducted through PubMed, Embase, and Google Scholar from inception until 2017. Publications only in English describing the epidemiology, pathophysiology, diagnostic criteria, and treatments of CHS were incorporated after thorough evaluation. National government surveys were also referred to for current information about the CHS patient population. RESULTS: CHS should be considered in the differential diagnosis of any patient presenting with persistent nausea and vomiting. In particular, the diagnosis is suggested if the patient demonstrates regular and chronic cannabis use, intractable nausea and vomiting, cyclical vomiting, relief of symptoms with hot baths, and resolution of symptoms after cannabis cessation. There are currently many possible explanations regarding the mechanisms behind CHS. A variety of treatment options have also been examined, including hot water baths, haloperidol, capsaicin, and benzodiazepines. CONCLUSIONS: CHS is becoming an increasingly prevalent and complicated problem for health care providers and patients. Further research must be done to address the diagnostic and therapeutic challenges of this syndrome.

Impacto de la instauración de un protocolo de actuación clínica ante el dolor abdominal en urgencias pediátricas / Impact of establishment of a clinical protocol for abdominal pain in pediatric emergencies

Objetivos: En enero de 2013 se implantó un protocolo de actuación para el manejo del dolor abdominal en el servicio de urgencias de pediatría, que pretendía reducir la realización de radiografías de abdomen no indicadas, disminuir la administración de enemas no indicados y aplicar una pauta de analgesia mayor. Se ha revisado el impacto del protocolo sobre la modificación de la práctica clínica y si estas variaciones se mantienen. Material y métodos: Estudio observacional, descriptivo, analítico y retrospectivo, realizado en 684 pacientes que acudieron al servicio de urgencias por presentar dolor abdominal de causa aparentemente no orgánica, distribuidos en cuatro periodos: diciembre de 2012 (P1), febrero de 2013 (P2), noviembre de 2013 (P3) y mayo de 2015 (P4). Se han recogido los datos sobre las pruebas diagnósticas realizadas y los tratamientos empleados en estos pacientes. Resultados: Radiografía abdominal: P1= 14,7%, P2= 6,9%, P3= 1,8%, P4= 0% (p <0,01); pacientes con estreñimiento: P1= 23,4%, P2= 13,5%, P3= 0%, P4= 0% (p= 0,001). Ecografía abdominal: P1= 11%, P2= 12,5%, P3= 9,4%, P4= 10,1% (p >0,05). Administración de enema en el servicio de urgencias: P1= 21,5%, P2= 8,3%, P3= 17,1%, P4= 11,7% (p= 0,005); pacientes con estreñimiento: P1= 51,1%, P2= 21,6%, P3= 31,3%, P4= 32,5% (p= 0,036). Tratamiento con polietilenglicol: P1= 4,3%, P2= 6,3%, P3= 9,8%, P4= 4,7% (p >0,05); pacientes con estreñimiento: P1= 12,8%, P2= 21,6%, P3= 40,6%, P4= 20,5% (p= 0,034). Pauta de analgesia: P1= 42,9%, P2= 53,5%, P3= 53,7%, P4= 62,7% (p= 0,02). Reconsultas al servicio de urgencias: P1= 10,4%, P2= 2,1%, P3= 1,8%, P4= 13% (p <0,01). Conclusiones: El protocolo ha logrado reducir de forma significativa la realización de radiografías abdominales y el empleo de enemas rectales. Ha aumentado la prescripción de analgesia en pacientes con dolor abdominal. El protocolo ha logrado homogeneizar la actuación de los profesionales, disminuyendo el riesgo de yatrogenia y aumentando el confort de los pacientes y sus familias (AU)

Objectives: In January 2013 a protocol for the management of abdominal pain at pediatric emergency was implanted, with the following objectives: reducing abdominal radiographs not indicated, reduce treatment with enemas not indicated and more prescription of analgesia. It has been reviewed the impact of the protocol on changing clinical practice and whether these variations are maintained. Material and methods: Retrospective, descriptive and analytical observational study with 684 patients attending emergency department for abdominal pain apparently no organic cause, divided into four periods: December 2012 (P1), February 2013 (P2), November 2013 (P3) and May 2015 (P4). We collected data about diagnostic tests performed and treatments used in these patients. Results: Abdominal radiography: P1= 14.7%, P2= 6.9%, P3= 1.8%, P4= 0% (p <0.01); constipated patients: P1= 23.4%, P2= 13.5%, P3= 0%, P4= 0% (p= 0.001). Abdominal ultrasound: P1= 11%, P2= 12.5%, P3= 9.4%, P4= 10.1% (p >0.05). Patients treated with rectal enema: P1= 21.5%, P2= 8.3%, P3= 17.1%, P4= 11.7% (p= 0.005); constipated patients: P1= 51.1%, P2= 21.6%, P3= 31.3%, P4= 32.5% (p= 0.036). Patients treated with polyethylenglycol: P1= 4.3%, P2= 6.3%, P3= 9.8%, P4= 4.7% (p >0.05); constipated patients: P1= 12.8%, P2= 21.6%, P3= 40.6%, P4= 20.5% (p= 0.034). Patients treated with analgesia: P1= 42.9%, P2= 53.5%, P3= 53.7%, P4= 62.7% (p= 0.02). Reconsultations the emergency department: P1= 10.4%, P2= 2.1%, P3= 1.8%, P4= 13% (p <0.01). Conclusions: The protocol has reduced significantly the performance of abdominal radiographs and use of rectal enemas. It has increased the prescription of analgesia in patients with abdominal pain. Protocol has managed to standardize the medical intervention, reducing the risk of iatrogenic and increasing comfort for patients and their families (AU)

Evaluación de los resultados antes y después de la implantación del Código Sepsis en Aragón / Before-after study of the effect of implementing a sepsis code for emergency departments in the community of Aragon

Objetivo. Estudiar el grado de cumplimiento del grupo de medidas de la Campaña Sobrevivir a la Sepsis (CSS) y su efecto en la mortalidad a corto plazo y tras la implantación de un código sepsis (CS) en Aragón. Método. Estudio cuasiexperimental que comparó dos cohortes antes (grupo pre-CS) y después (grupo pos-CS) de la implantación de un CS. Se seleccionaron retrospectivamente, a través de un registro administrativo, los episodios correspondientes a procesos infecciosos o con disfunción orgánica entre diciembre de 2012 y enero de 2013 (pre-CS) y entre diciembre de 2014 y enero de 2015 (pos-CS). El CS consistió en la activación electrónica desde triaje a partir de parámetros clínicos alterados, la definición de rutas de atención específica y la formación basada desde el triaje en la CSS. Las variables de resultado fueron porcentaje de cumplimiento del grupo de medidas de las CSS en las tres primeras horas desde la llegada a urgencias, mortalidad intrahospitalaria y a los 30 días. Resultados. Se incluyeron 222 pacientes en cada grupo. El porcentaje de cumplimiento fue mayor tras la implantación del CS respecto la aplicación del antibiótico en la primera hora (p = 0,100), la extracción de hemocultivos (p < 0,001), la determinación del ácido láctico (p < 0,001) y la aplicación de volumen aplicado/indicado (p < 0,001). La mortalidad intrahospitalaria fue de 31,1% en el grupo pre-CS y de 20,7% en el grupo pos-CS (p = 0,016) y la mortalidad a los 30 días fue de 30,1% en el grupo pre-CS y de 19,8% en el grupo pos-CS (p = 0,016). Conclusiones. La implantación de un CS ha mostrado una mejora en la aplicación de las medidas recomendadas y en la supervivencia a corto plazo (AU)

Objectives. To study the effect of an emergency department sepsis code on the degree of compliance with measures recommended by the Surviving Sepsis Campaign and short-term mortality in the Spanish Autonomous Community of Aragon. Material and methods. Quasi-experimental study of 2 case cohorts, one including of cases before implementation of the sepsis code and one included cases managed afterwards. We extracted retrospectively data from hospital records for infectious processes and organ failures between December 2012 and January 2013 for the pre-code group and between December 2014 and January 2015 for the post-code group. Staff training sessions on the campaign recommendations were provided and the code, which specified clinical pathways, was activated electronically on inputting clinical variables at the moment of triage. Outcome measures were the percentage of compliance with the campaign’s recommendations in the first 3 hours after a patient’s arrival at the emergency department in-hospital mortality, and 30-day mortality. Results. A total of 222 cases were included in each group. Compliance with the following campaign recommendations improved after implementation of the sepsis code: antibiotic therapy in the first hour (P=.100), extractions for blood cultures (P<.001), lactic acid measurement (P<.001), and recommended fluid loading (P<.001). In-hospital mortality was 31.1% in the pre-code cohort and 20.7% post-code; 30-day mortality rates were 30.1% and 19.8%, respectively (P=.016, all comparisons). Conclusion. Use of a sepsis code led to short-term improvement in how often the measures recommended by a sepsis survival campaign were put into practice (AU)

A trial of oral nifedipine and oral labetalol in preeclampsia hypertensive emergency treatment.

This observational retrospective cohort study was conducted to compare oral nifedipine and labetalol for emergency treatment of hypertension in preeclamptic patients. Time (minutes) and necessary doses were outlined to achieve blood pressure lower than 150/95 mmHg. In 14 patients with preeclampsia, 55 hypertensive emergencies were identified (BP >150/95). Of these emergencies, 43 were treated with oral nifedipine 10 mg (10 patients) and 12 with oral labetalol 100 mg (4 patients). To achieve a target blood pressure under 150/95, these doses were repeated as necessary every 20 min, up to a maximum of 4 doses. Oral nifedipine reduced BP more rapidly (31.30 vs. 53.50 min, p = .03). No maternal or foetal adverse events were observed and no major differences were found according to the type of delivery. Oral nifedipine is faster than and at least as safe as labetalol in pre-eclampsia hypertensive emergency treatment.

Perspectivas clínicas del manejo de la hemorragia en el paciente tratado con anticoagulante oral: estudio DECOVER / Clinical perspectives on the management of bleeding in patients on oral anticoagulants: the DECOVER Study (DElphi Consensus on oral COagulation and therapy action reVERsal)

Objetivo: Evaluar el grado de acuerdo entre hematólogos y urgenciólogos respecto a las mejores prácticas para el manejo de hemorragias y la reversión de la anticoagulación oral. Método: Estudio Delphi multicéntrico español con médicos expertos en anticoagulación y manejo de hemorragias. Se realizaron dos rondas de preguntas entre abril y septiembre de 2015. Se obtenía consenso cuando el 75% o más de los panelistas puntuaban en el mismo tercil. Resultados: Se encuestó a 15 hematólogos y 17 urgenciólogos de 14 comunidades autónomas. La hemodiálisis y la administración de concentrados de complejo protrombínico (CCP) activado fueron tratamientos consensuados para antagonizar una hemorragia relevante/mayor en pacientes tratados con dabigatrán. Para rivaroxabán y apixabán solo se consideró el CCP. El panel no valoró ningún CCP como eficaz y seguro a la vez. Los tiempos de tromboplastina parcial activado, trombina, ecarina y de trombina diluido se indicaron para pacientes tratados con dabigatrán y la actividad anti-Xa específica para los tratados con rivaroxabán y apixabán cuando presentan una hemorragia. Disponer de un antídoto específico para el tratamiento de los anticoagulantes orales de acción directa (ACOD) sería útil en caso de hemorragia grave (97%) y supondría un cambio sustancial en el algoritmo de tratamiento actual (97%). Conclusiones: Los resultados estuvieron en general alineados con las guías de práctica clínica, pero mostraron que existen áreas de mejora en la unificación de criterios sobre el manejo de los pacientes con hemorragias, y destacan la necesidad de disponer de antídotos específicos para ACOD (AU)

Objective: To evaluate the level of agreement between hematologists and emergency medicine physicians regarding the best clinical practices for managing bleeding and anticoagulant reversal. Methods: Nationwide Spanish multicenter Delphi method study with a panel of experts on anticoagulation and the management of bleeding. Two survey rounds were carried out between April and September 2015. Consensus was reached when more than 75% of the panelists scored items in the same tertile. Results: Fifteen hematologists and 17 emergency medicine specialists from 14 Spanish autonomous communities participated. Consensus was reached on the use of both hemodialysis and an activated prothrombin complex concentrate (PCC) to antagonize significant/major bleeding in patients taking dabigatran. Use of an activated PCC was considered sufficient for patients on rivaroxaban or apixaban. The panel did not consider any PCC to be both effective and safe. Tests for activated partial thromboplastin, thrombin, diluted thrombin, and ecarin clotting times were considered useful in patients treated with dabigatran. A specific anti-Xa activity assay was suggested for patients who developed bleeds while treated with rivaroxaban or apixaban. Specific antidotes for direct-acting oral anticoagulants would be useful when severe bleeding occurs according to 97% of the panelists. Such antidotes would substantially change current treatment algorithms. Conclusion: The points of consensus were generally in line with clinical practice guidelines, but the Delphi process revealed that there are aspects of the clinical management of bleeding that require unified criteria. The need for specific antidotes for direct-acting oral anticoagulants was emphasized (AU)

Pre-hospital treatment of bee and wasp induced anaphylactic reactions: a retrospective study.

BACKGROUND: Bee and wasp stings are among the most common triggers of anaphylaxis in adults representing around 20% of fatal anaphylaxis from any cause. Data of pre-hospital treatment of bee and wasp induced anaphylactic reactions are sparse. This study aimed to estimate the incidence of bee and wasp induced anaphylactic reactions, the severity of the reactions and to correlate the pre-hospital treatment with the severity of the anaphylactic reaction. METHODS: Retrospective and descriptive study based on data from the Mobile Emergency Care Units (MECUs) in the Region of Southern Denmark (2008 only for Odense and 2009-2014 for the whole region). Discharge summaries with diagnosis related to anaphylaxis according to the International Classification of Diseases 10 (ICD-10) were reviewed to identify bee and wasp induced anaphylactic reactions. The severity of the anaphylactic reaction was assessed according to Sampson's severity score and Mueller's severity score. Treatment was evaluated in relation to administration of adrenaline, glucocorticoids and antihistamine. RESULTS: We identified 273 cases (Odense 2008 n = 14 and Region of Southern Denmark 2009-2014 n = 259) of bee and wasp induced anaphylaxis. The Incidence Rate was estimated to 35.8 cases per 1,000,000 person year (95% CI 25.9-48.2) in the Region of Southern Denmark during 2009-2014. According to Sampson's severity score, 65% (n = 177) of the cases were graded as moderate to severe anaphylaxis (grade 3-5). Almost one third of cases could not be graded according to Mueller's severity score. Adrenaline was administrated in 54% (96/177) of cases with moderate to severe anaphylaxis according to Sampson's severity score, compared to 88% receiving intravenous glucocorticoids (p < 0.001) and 91% receiving intravenous antihistamines (p < 0.001). Even in severe anaphylaxis (grade 5) adrenaline was administered in only 80% of the cases. CONCLUSION: Treatment with adrenaline is not administered in accordance with international guidelines. However, making an assessment of the severity of the anaphylactic reaction is difficult in retrospective studies.

Requests for emergency hyperbaric oxygen treatment for carbon monoxide poisoning in Ankara, Turkey.

BACKGROUND: Carbon monoxide (CO) poisoning is common in Turkey. Our department is the main provider of emergency hyperbaric oxygen therapy (HBOT) in Ankara and neighboring cities. In this study, we analyzed the characteristics of CO-poisoned patients who were referred by phone to our department for emergency HBOT. METHODS: We retrospectively reviewed the records of phone consultations with emergency departments regarding the need for treatment of CO-poisoned patients with HBOT between 14 January 2014 and 14 January 2015. The following information was extracted from medical records: age, gender, CO source, exposure duration, carboxyhemoglobin (COHb) level, symptoms, electrocardiography (ECG) findings, cardiac enzymes, pregnancy, the distance of referring hospital to our centre, time between admission and consultation and HBOT decision. RESULTS: Over the one-year period, 562 patients with CO poisoning were referred for HBOT. We recommended HBOT for 289 (51%) patients. HBOT was recommended for 58% (n = 194) of the patients with COHb ≥ 25%, 72% (n = 163) of the patients with a history of syncope, 67% (n = 35) of the patients with ECG abnormality, and 67% (n = 14) of pregnant patients. Patients for whom HBOT was not recommended despite having positive signs of severe poisoning were referred significantly later compared to patients for whom HBOT was recommended. CONCLUSION: We found that the duration from admission to an emergency department to HBOT consultation affected our decision-making.

Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital.

BACKGROUND: Local anesthesia (LA) has been reported to be the best choice for elective open inguinal hernia repair because it is cost efficient, with less post-operative pain and enables more rapid recovery. However, the role of LA in emergency inguinal hernia repair is still controversial. The aim of this study is to investigate the safety and effectiveness of LA in emergency inguinal hernia repair. METHODS: All patients underwent emergency inguinal hernia repair in our hospital between January 2010 and April 2014 were analyzed retrospectively in this study. Patients were divided into LA and general anesthesia (GA) group according to the general conditions of the patients decided by anesthetists and surgeons. The outcome parameters measured included time to recovery, early and late postoperative complications, total expense and recurrence. RESULTS: This study included a total of 90 patients from 2010 to 2015. 32 patients (35.6%) were performed under LA, and 58 (64.4%) were performed under GA. LA group has less cardiac complications (P = 0.044) and respiratory complications (P = 0.027), shorter ICU stay (P = 0.035) and hospital stay (P = 0.001), lower cost (P = 0.000) and faster recovery time (P = 0.000) than GA group. CONCLUSION: LA could provide effective anesthesia and patient safety in emergency inguinal hernia repair.

¿Están cambiando nuestros paradigmas en la enfermedad traumática? / Are the paradigms in trauma disease changing?

Aunque la mortalidad por trauma supera los 5 millones al año en todo el mundo, con innumerables incapacidades y enormes costes, faltan estándares globales y uniformes para su organización y manejo. Los cambios en el conocimiento y los cuidados del paciente con trauma grave han sido espectaculares en las últimas décadas, pero los recursos en investigación, organización y cuidados no han crecido de forma paralela. En nuestro medio, la enfermedad traumática se sitúa muy por debajo de la investigación y organización de otras enfermedades graves. En los últimos años hemos cambiado nuestros modelos en investigación en trauma, organización, cambios en la reanimación inicial, la presencia de la TC como pieza clave en el manejo inicial, etc. Estos cambios actuales y de futuro del manejo del paciente traumatizado generan una valoración y tratamiento multidisciplinares, siendo necesaria la presencia del especialista en Medicina Intensiva como parte fundamental en el equipo de atención al trauma grave y su posterior cuidado en la unidad de críticos

Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit

Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study.

OBJECTIVES: The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. METHODS: The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. RESULTS: The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters. CONCLUSIONS: In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.

[Urgent cesarean section in a pregnant woman with carbon monoxide poisoning]. / Sürgosségi császármetszés szén-monoxid-mérgezésben.

Recognition of carbon monoxide is difficult due to its plain physical-chemical properties. Carbon and gas operating heating systems may cause severe poisoning. Carbon-monoxide intoxication may generate severe hypoxic damage and it may cause death. The authors present the case of severe carbon monoxide poisoning affecting one young child and five adults, including a pregnant woman. Because the availability of hyperbaric oxygen therapy is limited in Hungary, urgent cesarean section was performed to avoid intrauterine hypoxic damage. The authors note that there are no standardized non-invasive methods for measuring fetal carbon-monoxide level and that the level of carbon monoxide accumulation is higher and the clearance is longer in the fetus than in the mother. The pathophysiology of carbon monoxide intoxication and therapeutic options in pregnancy are discussed.

Alternative airways for the pediatric emergency department.

Securing the pediatric airway in the emergency setting is an uncommon event that is complicated by anatomic, physiologic, and environmental factors. Even more uncommonly, practitioners are faced with the added complication of a difficult airway, and the question of what alternatives to traditional endotracheal intubation are available and most useful may arise. Timely and effective intervention determines the patient's clinical outcome. The purpose of this review was to detail specific alternative airway management strategies and tools for use in the pediatric emergency department.