Intravenous lipid emulsion in the emergency department: a systematic review of recent literature.

BACKGROUND: Intravenous lipid emulsion (ILE) has been broadly attempted in the resuscitation of neurologic and cardiac toxic drug overdoses, however, the role of ILE in the emergency department is poorly defined. OBJECTIVE: This review aims to identify recent literature on the use of ILE in humans as an antidote and to familiarize emergency providers with the indications, availability, dosing recommendations, and adverse reactions associated with ILE use. METHODS: A systemic literature search of MEDLINE, EMBASE, and major toxicology conference abstracts was performed for human cases using ILE as an antidote with documented clinical outcomes through January 2014. RESULTS: Ninety-four published articles and 40 conference abstracts were identified, 85% of which had positive outcomes. The most common indication for ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic xenobiotics were tricyclic-antidepressants and verapamil. DISCUSSION: No standard of care is defined for the use of ILE, although the American Heart Association recommends use in LAST, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability resultant from lipid-soluble xenobiotics. ILE should be administered per American Society of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory interference, pancreatitis, respiratory distress syndrome, and interference with vasopressors should be considered as risks but are uncommon. CONCLUSIONS: In the setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may be considered for resuscitation by emergency physicians. As such, ILE may be stocked in emergency departments in close proximity to resuscitation rooms and areas where local nerve blocks are performed.

Chronic obstructive pulmonary disease: emergency care in acute exacerbation

Chronic obstructive pulmonary disease (COPD) is a preventable condition affecting more than 230 million people globally; and is expected to become the world's third largest cause of mortality by 2030. Despite this fact; it is thought to be widely underdiagnosed and underreported across the African continent. This presents a challenge to emergency medicine (EM) providers in the region; who are faced with treating large numbers of patients presenting with exacerbation of previously undiagnosed COPD. This is complicated by other factors; including lack of public awareness; high prevalence of other chronic respiratory illnesses; and difficulties in access to healthcare.The purpose of this paper is to outline the current state of research and international guidelines surrounding the management of acute exacerbation of COPD in the emergency centre. Strict adherence to international guidelines for management of acute exacerbation of COPD may be difficult for many African providers given factors affecting diagnosis; treatment; and access to care for many Africans suffering from COPD. Research looking into the role of the African EM practitioner in providing more cost-effective means of diagnosis and treatment of COPD is limited

Myocarditis.

Myocarditis is an inflammatory disease of the heart that can cause devastating disease in otherwise healthy children. Inciting agents such as viral infection cause direct damage to the myocardial cells, which triggers an inflammatory response that enhances myocardial toxicity and associated morbidity. Severe cases typically present with respiratory distress and cardiovascular collapse, whereas subclinical cases are unnoticed by the medical community. The initial workup in suspected cases should include an electrocardiogram, chest radiograph, and cardiac troponin T. Treatment is concentrated on hemodynamic stabilization with optimization of heart failure management, dysrhythmia protocol, and supportive therapy. The purpose of this review was to provide the emergency medicine practitioner a concise and current review of the basic pathophysiology as well as a functional and evidence-based approach to the diagnosis and treatment of myocarditis in the pediatric population.

Global uptake of the Humanitarian Accountability Partnership over its first ten years.

INTRODUCTION: Accountability in the delivery of humanitarian aid has become increasingly important and emphasized by the humanitarian community. The Humanitarian Accountability Partnership (HAP) was created in 2003 in order to improve accountability in the humanitarian sector. HAP acts as a self-regulatory body to the humanitarian system. One of the main goals of HAP is the promotion of accountability through self-regulation by members. Humanitarian nongovernmental organizations (NGOs) can become members by meeting standards of accountability and quality management set by HAP. This report describes the growth of HAP membership by the humanitarian community from its inception until present. Hypothesis/Problem The hypothesis for this study was that HAP membership has grown substantially since inception, both in terms of number of member organizations and annual budgets of member organizations, but that near universal membership has not yet been achieved. METHODS: A retrospective study was conducted to determine the total number and percentage of humanitarian NGOs that are members of HAP. Total expenditures of HAP members in 2010 also was measured and compared with the total humanitarian expenditure by all humanitarian NGOs for the same year. The reference year of 2010 was chosen in order to be able to compile accurate budgets for the largest possible number of HAP members. The total number of HAP members for the years 2005 through 2012 was divided by the estimated number of humanitarian NGOs active in 2010. The total budgets for HAP members in 2010 were divided by the estimated total humanitarian expenditure of all NGOs for 2010. RESULTS: As of the beginning of 2012, the percentage of humanitarian NGOs that were members of HAP was 1.6% (68 members out of 4400 organizations). The combined budgets of the member organizations of HAP in 2010 made up 62.9% of the total humanitarian expenditure for the year 2010 (US $4.65 billion/7.4 billion). CONCLUSION: A very small proportion of humanitarian NGOs have adopted HAP membership. However, HAP members account for almost two-thirds of all humanitarian expenditures. The humanitarian sector, therefore, remains without a universal regulatory and accountability structure, although progress has been made. Efforts should be made to increase the membership within HAP of more small to medium sized organizations.

Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies.

BACKGROUND: Emergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion. METHODS: We conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound. RESULTS: Sixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound. CONCLUSION: While currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

Is there an association between radiologist turnaround time of emergency department abdominal CT studies and radiologic report quality?

The aim of this study was to assess for an association between radiologists' turnaround time (TAT) and report quality for emergency department (ED) abdominopelvic CT examinations. Reports of 60 consecutive ED abdominopelvic CT studies from five abdominal radiologists (300 total reports) were included. An ED radiologist, abdominal radiologist, and ED physician independently evaluated satisfaction with report content (1-10 scale), satisfaction with report clarity (1-10 scale), and extent to which the report advanced the patient on a previously published clinical spectrum scale (1-5 scale). TAT (time between completion of imaging and completion of the final report) and report quality were compared between radiologists using unpaired t tests; associations between TAT and report quality scores for individual radiologists were assessed using Pearson's correlation coefficients. The five radiologists' mean TAT varied from 35 to 53 min. There were significant differences in report content in half of comparisons between radiologists by observer 1 (p ≤ 0.032) and in a minority of comparisons by observer 2 (p ≤ 0.047), in report clarity in majority of comparisons by observer 1 (p ≤ 0.031) and in a minority of comparisons by observer 2 (p ≤ 0.010), and in impact on patient care in a minority of comparisons for all observers (p ≤ 0.047). There were weak positive correlations between TAT and report content and clarity for three radiologists for observer 1 (r = 0.270-0.362) and no correlation between TAT and any report quality measure for remaining combinations of the five radiologists and three observers (r = -0.197 to +0.181). While both TAT and report quality vary between radiologists, these two factors were not associated for individual radiologists.

Barriers to utilization of pre-hospital emergency medical services among residents in Libreville, Gabon: a qualitative study

Introduction :In 2002; the West-African nation of Gabon established an emergency medical system (EMS); Service d'Aide Medicale Urgente (SAMU); in Libreville; yet few people access it. Our objective was to describe Libreville residents' knowledge and attitudes toward the SAMU in an effort to understand why this service is underutilized. Methods :Qualitative interviews consisting of nine open-ended questions were conducted on a convenience sample of twenty patients; three visitors and two patient/visitor dyads at the Jeanne Ebori Hospital Emergency Centre in October 2009. Eligible subjects arrived in vehicles other than the SAMU and were ill enough to require hospital admission. Exclusion criteria were: under 21years old; unable to speak French; or medically unstable. A bilingual team member audio-recorded the interviews in French and transcribed them into eng. Investigators organized text into codes; then into themes and theoretical constructs. Intercoder agreement was excellent. Data were collected until theoretical saturation was achieved. Results: Analysis of data revealed no difference in response between patients and visitors. People underused SAMU because of financial costs; lack of awareness of the program; use of traditional modes of transportation; infrastructure flaws; perceived response times and other misconceptions. Conclusion: We identified remediable barriers to EMS (SAMU) access in Libreville; Gabon: lack of awareness; misperceptions; established alternatives; and cost. Interventions and future investigations designed to increase EMS utilization in Gabon should target these four areas

mHealth in Sub-Saharan Africa.

Mobile phone penetration rates have reached 63% in sub-Saharan Africa (SSA) and are projected to pass 70% by 2013. In SSA, millions of people who never used traditional landlines now use mobile phones on a regular basis. Mobile health, or mHealth, is the utilization of short messaging service (SMS), wireless data transmission, voice calling, and smartphone applications to transmit health-related information or direct care. This systematic review analyzes and summarizes key articles from the current body of peer-reviewed literature on PubMed on the topic of mHealth in SSA. Studies included in the review demonstrate that mHealth can improve and reduce the cost of patient monitoring, medication adherence, and healthcare worker communication, especially in rural areas. mHealth has also shown initial promise in emergency and disaster response, helping standardize, store, analyze, and share patient information. Challenges for mHealth implementation in SSA include operating costs, knowledge, infrastructure, and policy among many others. Further studies of the effectiveness of mHealth interventions are being hindered by similar factors as well as a lack of standardization in study design. Overall, the current evidence is not strong enough to warrant large-scale implementation of existing mHealth interventions in SSA, but rapid progress of both infrastructure and mHealth-related research in the region could justify scale-up of the most promising programs in the near future.

Global Emergency Medicine: a review of the literature from 2012.

OBJECTIVES: The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and grey literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. METHODS: This year, our search identified 4,818 articles written in six languages. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Two additional reviewers searched and screened the grey literature. A total of 224 articles were deemed appropriate by at least one reviewer and were approved by their editor for formal scoring of overall quality and importance. RESULTS: Of the 224 articles that met our predetermined inclusion criteria, 56% were categorized as Emergency Care in Resource-limited Settings, 18% as EM development, and 26% as Disaster and Humanitarian Response. A total of 28 articles received scores of 16 or higher and were selected for formal summary and critique. Inter-rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.625 (95% confidence interval = 0.512 to 0.711). CONCLUSIONS: In 2012 there were more disaster and humanitarian response articles than in previous years. As in prior years, the majority of articles addressed the acute management of infectious diseases or the care of vulnerable populations such as children and pregnant women.

Review of recently approved alternatives to anticoagulation with warfarin for emergency clinicians.

BACKGROUND: Dabigatran and rivaroxaban are novel anticoagulants that have been approved for the prevention of thromboembolic events in atrial fibrillation. These medications are attractive to both patients and clinicians, as, unlike warfarin, they do not require laboratory monitoring or dietary restrictions. However, they carry bleeding risks similar to that of warfarin and are without a reliable reversal agent. OBJECTIVES: The objectives of this article are to 1) summarize the pivotal trials leading to the U.S. Food and Drug Administration approvals of dabigatran (Pradaxa; Boehringer Ingelheim, Ridgefield, CT) and rivaroxaban (Xarelto; Janssen Pharmaceuticals, Inc., Titusville, NJ); 2) present the limited data available regarding the management of bleeding patients on these agents; and 3) provide suggestions to guide emergency providers given the limited data. DISCUSSION: Dabigatran and rivaroxaban were approved based on large, non-inferiority trials comparing the new agents to warfarin with stroke or systemic embolism as the primary outcome. Traditional coagulation studies cannot be used to determine the degree of anti-coagulation produced by these agents. Fresh frozen plasma is unlikely to be effective in patients on these drugs who are acutely bleeding. Prothrombin complex concentrate can be considered in patients on rivaroxaban. Dabigatran is renally cleared, so dabigatran could be removed by hemodialysis. Theoretically, DDAVP (Sanofi-Aventis U.S. LLC, Bridgewater, NJ), aminocaproic acid, tranexamic acid, or recombinant activated factor VII could also be used in an attempt to control bleeding. CONCLUSION: There is a need for assays for the degree of anticoagulation produced by drugs such as dabigatran and rivaroxaban. Additionally, studies are needed to evaluate reversal agents that could be effective in the setting of acute bleeding.

Recommendations for additional imaging on emergency department CT examinations: comparison of emergency- and organ-based subspecialty radiologists.

PURPOSE: Past studies have identified a high frequency of recommendations for additional imaging (RAI) for computed tomography (CT) studies performed in an emergency department (ED), thereby potentially contributing to increased imaging utilization and costs. The purpose of this study was to compare rates of RAI within the ED setting between ED-based and organ-based subspecialty radiologists. METHODS: We identified 600 ED CT studies, comprising 200 head, chest, and abdominal CT studies, split equally between cases reviewed by ED-based and organ-based radiologists. Frequency of RAI for the three examinations was compared between these subspecialty groups. RESULTS: Frequencies of RAI were 21.5 %, 13.5 %, and 5.5 % for CT examinations of the chest, abdomen, and brain, respectively. There was a significantly higher frequency of RAI for chest CT studies interpreted by chest radiologists than by ED radiologists (28.0 % vs. 15.0 %, respectively, p = 0.036), largely due to a higher rate of RAI for incidentally detected lung nodules and masses as well as other pulmonary parenchymal abnormalities by chest radiologists. There was no significant difference in RAI on brain or abdominal CT studies between the two groups (p = 0.426-1.0). However, on abdominal studies, only ED-based radiologists provided RAI for abnormalities of the bowel or uterus, while only organ-based radiologists provided RAI for pancreatic abnormalities. Only 25.6 % of RAI were subsequently performed at our institution. CONCLUSION: For chest CT studies performed at the authors' institution, differences in management of incidental pulmonary nodules contributed to a significantly higher frequency of RAI by chest radiologists than by ED-based radiologists. Further investigation of the impact of these differences on cost and patient outcomes is warranted.

Global emergency medicine: a review of the literature from 2011.

OBJECTIVES: The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of published and unpublished articles relevant to global emergency medicine (EM) to identify, review, and disseminate the most important research in this field to a wide audience of academics and practitioners. METHODS: This year, 7,924 articles written in seven languages were identified by our search. These articles were divided up among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the grey literature. A total of 206 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of their overall quality and importance. RESULTS: Of the 206 articles that met our predetermined inclusion criteria, 24 articles received scores of 17 or higher and were selected for formal summary and critique. Interrater reliability for our scoring system was good with an interclass correlation coefficient of 0.628 (95% confidence interval = 0.51 to 0.72). CONCLUSIONS: Compared to previous reviews, there was a significant increase in the number of articles that were devoted to emergency care in resource-limited settings, with fewer articles related to disaster and humanitarian response. The majority of articles that met our selection criteria were reviews that examined the efficacy of particular treatment regimens for diseases that are primarily seen in low- and middle-income countries.

Identification of current priorities for research in humanitarian action: proceedings of the First Annual UN OCHA Policy and Research Conference.

On December 12-13, 2011, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) hosted a humanitarian policy and research conference on the theme of "Risk, Adaptation and Innovation in Humanitarian Action." The four sessions of the conference covered humanitarian action in a changing world, adaptation and innovation in humanitarian action, humanitarian action in protracted and violent conflict, and effective humanitarian action. This special report contains summaries of presentations in each session and the conclusions resulting from the discussions throughout. Through a process of open discussion, debate, and a closing survey, the conference participants identified four top priorities in humanitarian research for the coming years: evidence-driven humanitarian decision-making; accountability and transparency; risk and agility; and partnership. In addition to plans for a 2nd Annual Research and Policy conference in December of 2012, specific outcomes of the conference include a series of regional workshops in 2012 and 2013, launching with Asia, Africa and the Middle East; creation of Policy Working Groups (PWG) for each research priority identified; and a new flagship OCHA publication, to be launched in late 2012 or early 2013, which will share the progress made on the research priorities identified.

International emergency medicine: a review of the literature from 2010.

The International Emergency Medicine (IEM) Literature Review aims to highlight and disseminate high-quality global EM research in the fields of EM development, disaster and humanitarian response, and emergency care in resource-limited settings. For this review, we conducted a Medline search for articles published between January 1 and December 31, 2010, using a set of international and EM search terms and a manual search of journals that have produced large numbers of IEM articles for past reviews. This search produced 6,936 articles, which were divided among 20 reviewers who screened them using established inclusion and exclusion criteria to select articles relevant to the field of IEM. Two-hundred articles were selected by at least one reviewer and approved by an editor for scoring. Two independent reviewers using a standardized and predetermined set of criteria then scored each of the 200 articles. The 27 top-scoring articles were chosen for full review. The articles this year trended toward evidence-based research for treatment and care options in resource-limited settings, with an emphasis on childhood illness and obstetric care. These articles represent examples of high-quality international emergency research that is currently ongoing in high-, middle-, and low-income countries alike. This article is not intended to serve as a systematic review or clinical guideline but is instead meant to be a selection of current high-quality IEM literature, with the hope that it will foster further growth in the field, highlight evidence-based practice, and encourage discourse.