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1.
Prehosp Disaster Med ; 36(4): 375-379, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34039457

RESUMO

INTRODUCTION: Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE. STUDY OBJECTIVE: The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE. METHODS: This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed. RESULTS: All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s). CONCLUSION: There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

2.
J Emerg Med ; 61(2): 172-173, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34006417

RESUMO

BACKGROUND: Iatrogenic pulmonary air embolism is a fairly common and sometimes deadly complication of i.v. contrast injection. CASE REPORT: We present the case of a 33-year-old man with a symptomatic iatrogenic injection air embolism and resolution within 5 h. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the importance of computed tomography imaging in emergency medicine, clinicians should be aware of the risk for injection air embolism from i.v. contrast injection.


Assuntos
Embolia Aérea , Embolia Pulmonar , Adulto , Embolia Aérea/etiologia , Humanos , Doença Iatrogênica , Masculino , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Tomografia Computadorizada por Raios X
4.
Acad Emerg Med ; 28(10): 1160-1172, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34021515

RESUMO

OBJECTIVES: Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS: Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS: Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION: CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.

5.
Am J Emerg Med ; 45: 1-6, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33639293

RESUMO

CONTEXT: Febrile neutropenic immunocompromised children are at a high risk of Serious Bacterial Infections (SBI). OBJECTIVE: This systematic review and meta-analysis report the prevalence of SBI in healthy children with febrile neutropenia. DATA SOURCE: PubMed, EMBASE, and Web of Science from their inception to August 2020. STUDY SELECTION: Patients with an Absolute Neutrophil Count (ANC) <1000 cells/mm3 up to 18 years of age presenting to the ED with a chief complaint of fever (temperature > 38°C) and who had a workup for SBI as defined by each study. DATA ABSTRACTION: Data from individual studies was abstracted by a subset of the authors and checked independently by the senior author. Any discrepancies were adjudicated by the joint agreement of all the authors. We calculated the prevalence of SBI by using the number of SBI's as the numerator and the total number of febrile events in patients as the denominator. Bias in our studies was quantified by the Newcastle Ottawa Scale. RESULTS: We identified 2066 citations of which five studies (1693 patients) our inclusion criteria. None of our reviewed studies consistently tested every included patient for SBI. Spectrum bias in every study resulted in a wide range of the SBI prevalence of 1.9% (<0.01% - 11%) similar to non-neutropenic children. LIMITATIONS: All of our studies were retrospective and many did not consistently screen all subjects for SBI. CONCLUSION: If the clinical suspicion is low, the risk for SBI is similar between febrile healthy neutropenic and non-neutropenic children.


Assuntos
Infecções Bacterianas/epidemiologia , Febre/microbiologia , Neutropenia/microbiologia , Criança , Humanos , Prevalência
6.
Am J Emerg Med ; 40: 225.e1-225.e2, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32958382

RESUMO

BACKGROUND: Patients with flank pain and hematuria are common emergency department presentations of nephrolithiasis. We may anchor on this etiology and potentially miss other less common differentials. We present a case of a patient with hematuria and flank pain typical of nephrolithiasis who was diagnosed with a Page kidney causing secondary hypertension. A 50 year-old male with no significant past medical history presented to the Emergency Department with severe left-sided flank pain, vomiting, and blood-tinged urine. We pursued a diagnosis of nephrolithiasis and found a left renal subcapsular hematoma on non-contrast CT. A CTA was done with no active hemorrhage found. The patient had no history of recent trauma and was found to be hypertensive on evaluation. Urology was consulted and management for the patient's hypertension was initiated. He was diagnosed with Page Kidney and admitted to medicine for observation and hypertension management with an angiotensin-converting enzyme inhibitor. Page Kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system. Causes may include traumatic subcapsular hematoma, renal cyst rupture, tumor, hemorrhage, arteriovenous malformation, among others. Treatment may involve conservative measures including hypertension management, or more invasive measures like evacuation or nephrectomy. We describe the case of a patient presumed to have nephrolithiasis presenting with typical left-sided flank pain, diagnosed with Page kidney, and treated conservatively.


Assuntos
Hipertensão Renal/diagnóstico , Nefrite/diagnóstico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Diagnóstico Diferencial , Dor no Flanco , Hematúria , Humanos , Hipertensão Renal/tratamento farmacológico , Cálculos Renais/diagnóstico , Masculino , Pessoa de Meia-Idade , Nefrite/tratamento farmacológico
7.
Am J Emerg Med ; 39: 180-189, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33067062

RESUMO

BACKGROUND: Ventriculoperitoneal (VP) shunt malfunction is an emergency. Timely diagnosis can be challenging because shunt malfunction often presents with symptoms mimicking other common pediatric conditions. METHODS: We performed a systematic review and meta-analysis to determine which commonly used imaging modalities; Magnetic resonance imaging (MRI), Computed Tomography (CT), X-ray Shunt series or Optic Nerve Sheath Diameter (ONSD) ultrasound, are superior in evaluating shunt malfunction. INCLUSION CRITERIA: patients less than 21 years old with symptoms of shunt malfunction. We calculated the pooled sensitivity, specificity, Likelihood Ratios (LR+, LR-) using a random-effects model. RESULTS: Eight studies were included encompassing 1906 patients with a prevalence of VP shunt malfunction of (29.3%). Shunt series: sensitivity (14%-53%), specificity (99%), LR+ (23.2), and LR- (0.47-0.87). CT scan: sensitivity (53%-100%), specificity (27%-98%), LR+ (1.34-22.87), LR- (0.37). MRI: sensitivity (57%), specificity (93%), LR+ (7.66), and LR- (0.49). ONSD: sensitivity (64%), specificity (22%-68%), LR+ (4.4-8.7), LR- (0.93). A positive shunt series, CT scan, MRI, or ONSD has a post-test probability of (23%-84%). A normal shunt series, CT scan, MRI, or ONSD results in a post-test probability of (7%-31%). A positive shunt series results in a post-test probability of 80%, which is equivalent to the post-test probability of CT scan (23-84%) and MRI (83%). CONCLUSION: Despite the low sensitivity, a positive shunt series obviates the need for further imaging studies. Prompt referral for neurosurgical intervention is recommended. A negative shunt series or any result (positive or negative) from CT, MRI, or ONSD will still require an emergent neurosurgical referral.


Assuntos
Imageamento por Ressonância Magnética , Falha de Prótese , Tomografia Computadorizada por Raios X , Ultrassonografia , Derivação Ventriculoperitoneal , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Pediatria , Sensibilidade e Especificidade
8.
Pediatr Emerg Care ; 37(2): 108-118, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-30870341

RESUMO

OBJECTIVE: To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. METHODS: We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. RESULTS: Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. CONCLUSIONS: In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.

9.
Pediatrics ; 147(1)2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33277351

RESUMO

BACKGROUND: Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children. METHODS: Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated. RESULTS: The UTI prevalence was 9.2%, with the most common pathogen being Escherichia coli (75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria. CONCLUSIONS: The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.


Assuntos
Funções Verossimilhança , Infecções Urinárias/diagnóstico , Centros Médicos Acadêmicos , Hidrolases de Éster Carboxílico/urina , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência , Escherichia coli/isolamento & purificação , Infecções por Escherichia coli/diagnóstico , Feminino , Humanos , Lactente , Contagem de Leucócitos , Masculino , Nitritos/urina , Prevalência , Estudos Retrospectivos , População Urbana , Urinálise , Infecções Urinárias/microbiologia
10.
J Emerg Med ; 59(3): 459-465, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32595053

RESUMO

BACKGROUND: Increasing emergency department (ED) utilization has contributed to ED overcrowding, with longer ED length of stay (EDLOS) and more patients leaving without being seen (LWBS), and is associated with higher morbidity and mortality rates. Previous studies of provider in triage (PIT) have shown decreased LWBS, but variable improvements in EDLOS. OBJECTIVES: We evaluated the impact of PIT implementation in an urban safety-net hospital on commonly reported ED throughput metrics. METHODS: This before-and-after study was performed at an academic urban safety hospital. We implemented a PIT team that screened ambulatory ED patients for early discharge or expedited workup. The PIT intervention was implemented 3 days a week from January through April 2019. As controls, we compared throughput metrics from when PIT was unavailable (Group 2) and from 1 year prior (Group 3). RESULTS: There were significantly (p < 0.001) lower rates of LWBS in Group 1 (4.8%, 95% confidence interval [CI] 4.1-5.8%) compared with 2 (7.3%, 95% CI 5.5-9.7%) and 3 (7.8%, 95% CI 6.9-9.0%). Door-to-doctor times were significantly (p < 0.001) lower for Group 1 (148 min, interquartile range [IQR] 88, 226 min) compared with 2 (187 min, IQR 95.5, 266 min) and 3 (215 min, IQR 131, 290 min). EDLOS was significantly (p < 0.001) shorter for Group 1 (337 min, IQR 215, 468 min) compared with 2 (385 min, IQR 271, 516 min) and 3 (413 min, IQR 299, 538 min). CONCLUSIONS: We found significantly lower LWBS rates, shorter EDLOS, and shorter door-to-doctor times after PIT implementation. Compared with previous studies in a variety of settings, we found that PIT significantly improved LWBS and all throughput metrics in a safety net setting.


Assuntos
Provedores de Redes de Segurança , Triagem , Serviço Hospitalar de Emergência , Hospitais Urbanos , Humanos , Tempo de Internação , Estudos Retrospectivos
11.
Am J Emerg Med ; 38(11): 2492.e5-2492.e6, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32532619

RESUMO

Early reports of COVID-19 in pediatric populations emphasized a mild course of disease with severe cases disproportionately affecting infant and comorbid pediatric patients. After the peak of the epidemic in New York City, in late April to early May, cases of severe illness associated with COVID-19 were reported among mostly previously healthy children ages 5-19. Many of these cases feature a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of SARS-CoV-2 positive diagnostic testing and the CDC has termed this presentation Multisystem Inflammatory Syndrome (MIS-C). It is essential to disseminate information among the medical community regarding severe and atypical presentations of COVID-19 as prior knowledge can help communities with increasing caseloads prepare to quickly identify and treat these patients as they present in the emergency department. We describe a case of MIS-C in a child who presented to our Emergency Department (ED) twice and on the second visit was found to have signs of distributive shock, multi-organ injury and systemic inflammation associated with COVID-19. The case describes two ED visits by an 11- year-old SARS-CoV-2-positive female who initially presented with fever, rash and pharyngitis and returned within 48 hours with evidence of cardiac and renal dysfunction and fluid-refractory hypotension requiring vasopressors and PICU admission.


Assuntos
COVID-19/complicações , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , COVID-19/diagnóstico , COVID-19/virologia , Criança , Exantema/virologia , Feminino , Febre/virologia , Humanos , Faringite/virologia , Síndrome de Resposta Inflamatória Sistêmica/virologia
12.
Am J Emerg Med ; 38(8): 1662-1670, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32505473

RESUMO

INTRODUCTION: Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES: The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS: We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS: Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION: Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.


Assuntos
Serviço Hospitalar de Emergência , Tempo de Internação , Triagem , Aglomeração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Triagem/métodos , Triagem/organização & administração
14.
Pediatr Emerg Care ; 36(5): 236-239, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32229786

RESUMO

Burnout among emergency medicine (EM) physicians (57%) is significantly greater than among pediatricians (39%). Pediatric EM (PEM) providers are a unique population in that the majority first complete a pediatric residency and then a fellowship in pediatric emergency medicine. We sought to evaluate the prevalence and risk factors for burnout in PEM fellows. METHODS: An e-mail survey that included the Maslach Burnout Inventory (MBI) Health Services Survey was sent to fellows in PEM programs. Anonymous surveys were scored using the MBI subscales of emotional exhaustion and depersonalization. Fellows with scores of moderate to high in both emotional exhaustion and depersonalization were considered to have burnout. The data were compared with demographic information, including fellowship year, sex, and relationship status. Participants were also asked to list items in their life they felt were burnout contributors. The burnout rate was reported as a percentage with 95% confidence intervals (95% CI), based on the Agresti-Coull method. Associations between categorical variables and burnout were tested with Fisher exact test, alpha = 0.05 (2 tails). RESULTS: Of 463 PEM fellows, 146 responses were received (30% response rate), and 139 surveys were scored. Over half (65%) of the respondents were female. The burnout prevalence of PEM fellows was 30.9% (95% CI, 24%-39%). The burnout rate was significantly (P = 0.002) lower for men (13%) (95% CI, 6%-26%) than for women (39.8%) (95% CI, 30%-50%). Fellows who were single (50%) or divorced (66.7%) had significantly (P = 0.008) higher rates of burnout compared with married (27%) fellows. Current training year was not a significant burnout risk. Major contributors to burnout were work environment (52.5%), academic responsibilities of fellowship (36%), schedule (35.3%), work-life balance (33.8%), and career / occupational stress (33.1%). CONCLUSIONS: Pediatric emergency medicine fellows had a 30.9% prevalence of burnout. Risk factors for burnout were similar for PEM fellows and EM physicians. Women were more likely to suffer from burnout, as well as fellows who were single or divorced.


Assuntos
Esgotamento Profissional/epidemiologia , Educação de Pós-Graduação em Medicina , Medicina de Emergência Pediátrica/educação , Pediatras/psicologia , Adulto , Despersonalização , Bolsas de Estudo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos/psicologia , Prevalência , Fatores de Risco , Fatores Sexuais , Inquéritos e Questionários , Estados Unidos/epidemiologia
16.
Europace ; 22(6): 854-869, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32176779

RESUMO

AIMS: We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF). METHODS AND RESULTS: We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low. CONCLUSION: For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.


Assuntos
Amiodarona , Fibrilação Atrial , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Teorema de Bayes , Cardioversão Elétrica , Humanos , Metanálise em Rede , Resultado do Tratamento
17.
Pediatr Emerg Care ; 2020 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-32118837

RESUMO

BACKGROUND: Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures. OBJECTIVES: We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients. METHODS: We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc. RESULTS: Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of ~2% would require a negative skull ultrasound in a patient with only a pretest probability of ~15%. CONCLUSIONS: A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.

18.
Ann Emerg Med ; 76(1): 14-30, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32173135

RESUMO

STUDY OBJECTIVE: We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED). METHODS: We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook. RESULTS: The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency. CONCLUSION: For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Flutter Atrial/tratamento farmacológico , Antiarrítmicos/farmacologia , Fibrilação Atrial/fisiopatologia , Flutter Atrial/fisiopatologia , Teorema de Bayes , Serviço Hospitalar de Emergência , Humanos , Metanálise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
19.
J Med Toxicol ; 16(2): 222-229, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31907741

RESUMO

OBJECTIVES: Metformin-associated lactic acidosis (MALA) may occur after acute metformin overdose, or from therapeutic use in patients with renal compromise. The mortality is high, historically 50% and more recently 25%. In many disease states, lactate concentration is strongly associated with mortality. The aim of this systematic review and meta-analysis is to investigate the utility of pH and lactate concentration in predicting mortality in patients with MALA. METHODS: We searched PubMed, EMBASE, and Web of Science from their inception to April 2019 for case reports, case series, prospective, and retrospective studies investigating mortality in patients with MALA. Cases and studies were reviewed by all authors and included if they reported data on pH, lactate, and outcome. Where necessary, authors of studies were contacted for patient-level data. Receiver operating characteristic (ROC) curves were generated for pH and lactate for predicting mortality in patients with MALA. RESULTS: Forty-four studies were included encompassing 170 cases of MALA with median age of 68.5 years old. Median pH and lactate were 7.02 mmol/L and 14.45 mmol/L, respectively. Overall mortality was 36.2% (95% CI 29.6-43.94). Neither lactate nor pH was a good predictor of mortality among patients with MALA. The area under the ROC curve for lactate and pH were 0.59 (0.51-0.68) and 0.43 (0.34-0.52), respectively. CONCLUSION: Our review found higher mortality from MALA than seen in recent studies. This may be due to variation in standard medical practice both geographically and across the study interval, sample size, misidentification of MALA for another disease process and vice versa, confounding by selection and reporting biases, and treatment intensity (e.g., hemodialysis) influenced by degree of pH and lactate derangement. The ROC curves showed poor predictive power of either lactate or pH for mortality in MALA. With the exception of patients with acute metformin overdose, patients with MALA usually have coexisting precipitating illnesses such as sepsis or renal failure, though lactate from MALA is generally higher than would be considered survivable for those disease states on their own. It is possible that mortality is more related to that coexisting illness than MALA itself, and many patients die with MALA rather than from MALA. Additional work looking solely at MALA in healthy patients with acute metformin overdose may show a closer relationship between lactate, pH, and mortality.


Assuntos
Equilíbrio Ácido-Base/efeitos dos fármacos , Acidose Láctica/mortalidade , Hipoglicemiantes/efeitos adversos , Ácido Láctico/sangue , Metformina/efeitos adversos , Acidose Láctica/sangue , Acidose Láctica/induzido quimicamente , Acidose Láctica/fisiopatologia , Idoso , Biomarcadores/sangue , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco
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