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1.
Ann Emerg Med ; 2020 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-32046869

RESUMO

STUDY OBJECTIVE: We determine the accuracy of high-sensitivity cardiac troponin I (hs-cTnI), European-derived, rapid, acute myocardial infarction, rule-out/rule-in algorithms applied to a US emergency department (ED) population. METHODS: Adults presenting to the ED with suspected acute myocardial infarction were included. Plasma samples collected at baseline and between 40 and 90 minutes and 2 and 3 hours later were analyzed in core laboratories using the Siemens Healthineers hs-cTnI assays. Acute myocardial infarction diagnosis was independently adjudicated. The sensitivity, specificity, and negative and positive predictive values for rapid acute myocardial infarction rule-out/rule-in using European algorithms and 30-day outcomes are reported. RESULTS: From 29 US medical centers, 2,113 subjects had complete data for the 0/1-hour algorithm analyses. With the Siemens Atellica Immunoassay hs-cTnI values, 1,065 patients (50.4%) were ruled out, with a negative predictive value of 99.7% and sensitivity of 98.7% (95% confidence interval 99.2% to 99.9% and 96.3% to 99.6%, respectively), whereas 265 patients (12.6%) were ruled in, having a positive predictive value of 69.4% and specificity of 95.7% (95% confidence interval 63.6% to 74.7% and 94.7% to 96.5%, respectively). The remaining 783 patients (37.1%) were classified as having continued evaluations, with an acute myocardial infarction incidence of 5.6% (95% confidence interval 4.2% to 7.5%). The overall 30-day risk of death or postdischarge acute myocardial infarction was very low in the ruled-out patients but was incrementally increased in the other groups (rule-out 0.2%; continued evaluations 2.1%; rule-in 4.8%). Equivalent results were observed in the 0/2- to 3-hour analyses and when both algorithms were applied to the hs-cTnI ADVIA Centaur measurements. CONCLUSION: The European rapid rule-out/rule-in acute myocardial infarction algorithm hs-cTnI cut points can be harmonized with a demographically and risk-factor diverse US ED population.

2.
J Trauma Acute Care Surg ; 88(2): 279-285, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31738314

RESUMO

BACKGROUND: Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients. METHODS: Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices. RESULTS: A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30. CONCLUSION: The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing. LEVEL OF EVIDENCE: Diagnostic test, level II.

3.
Wound Repair Regen ; 28(1): 26-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31606927

RESUMO

Burn conversion from second to third degree is common leading to delayed healing and scarring. We hypothesized that tadalafil, a phosphodiesterase 5 inhibitor (PDE5I) that results in vasodilation, would reduce burn conversion leading to faster reepithelialization and less scarring of partial thickness porcine burns. We conducted a prospective, randomized, controlled, animal experiment using six female pigs (25-30 kg). We created 20 standardized partial thickness burns on each of the animals with an aluminum bar preheated to 80 °C and applied for 20 seconds to the pigs' dorsum. Three animals each were randomized to oral tadalafil 2.5 mg or control vehicle once daily for 1 week. Main outcomes were time to reepithelialization and depth of scarring at 28 days. A sample of 60 burns in each treatment group had 80% power to detect a 2-day difference in time to reepithelialization. Mean (95% CI) time to reepithelialization in burns treated with tadalafil and control were 14.9 (14.1-15.7) vs. 19.7 (18.2-21.3) days, respectively; mean difference 4.8 (3.1-6.6) days. After controlling for pig and within pig differences, mean time to reepithelialization was 6.5 (3.7-9.3) days shorter in burns treated with tadalafil compared with controls. Mean (95% CI) scar depth in burns treated with tadalafil and control were 2.7 (2.3-3.1) vs. 3.7 (3.1-4.2) mm. respectively, mean difference 1 (0.3-1.7) mm. After controlling for pig and within pig differences, scar depth in tadalafil-treated burns was 1.5 (0.7-2.3) mm lower compared with controls. We conclude that once daily oral tadalafil shortened time to reepithelialization and reduced scarring in a partial thickness porcine burns model.

4.
Burns ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31859098

RESUMO

Several scoring systems, such as the Baux score, help predict outcomes in burn patients. The quick Sequential Organ Failure Assessment (qSOFA) score (composed of a respiratory rate of 22/min or greater, systolic blood pressure of 100 mmHg or less, and altered mental status) is a new bedside index proposed to help identify patients with suspected infection at risk of complications. We hypothesized that qSOFA scores would be associated with in-hospital mortality, ICU admission, and length of stay (LOS) in patients with burns. We performed a retrospective review of all burn patients admitted between January 2010-March 2017 at an academic, suburban, hospital with a regional burn center. qSOFA scores were calculated as 1 point each for GCS<15, RR≥22, and SBP≤100. A qSOFA value of>2 was considered high risk. Revised Baux (rBaux) scores were calculated as age +%TBSA burned +17 (if inhalation injury). A rBaux score >140 was considered high risk. Univariate, multivariate and receiver operating characteristics analyses were performed to compare qSOFA and rBaux scores. There were 1039 burn admissions during the study period. Mean age was 30 ± 24 years, 66% were male. Mean TBSA was 10 ± 12%, mean injury severity score was 5 ± 8. Mean hospital LOS was 8 ± 24 days, 22 patients (2.1%) died. qSOFA scores were associated with mortality and ICU admission. Of all patients, 80 were high risk by qSOFA and 7 by Baux scores. ROC characteristics of qSOFA and Baux scores for predicting death were sensitivity 36% vs. 32%, specificity 94% vs. 100%, PPV 13% vs. 100%, and NPV 98% vs. 99% respectively. The AUC for qSOFA (0.68 [95% CI, 0.54-0.81]) was lower than for Baux (0.99 [95%CI, 0.99-1.00]). Youden's index identified an optimal cutoff of 85 on the Baux score yielding sensitivity 100%, specificity 94%, PPV 27%, and NPV 100% for mortality. Our results indicate that while qSOFA scores were associated with outcomes, a rBaux score had greater predictive value. The optimal rBaux score for predicting all mortality and ICU admission was 85.

5.
Am J Emerg Med ; 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31884025

RESUMO

BACKGROUND: Hyperkalemia (HK) is common and associated with mortality. Our purpose was to determine if the rapid correction of elevated serum potassium level (K+) was associated with reduced mortality in emergency department (ED) patients. METHODS: Design: We reviewed the electronic medical records (EMR) of ED patients with HK (K+ ≥ 5.5 mEq/L) from 10/2016-10/2017. SETTING: Large, academic ED. PARTICIPANTS: Adult ED patients presenting with hyperkalemia. Main outcomes and measures: The main outcome was in-hospital mortality. We compared outcomes of patients whose K+ normalized (dropped below 5.5 mEq/L) with those whose K+ did not normalize using chi-square and multivariate analyses to determine the associations between predictor variables and outcomes. RESULTS: From 114,977 ED visits, 1033 patients (0.9%, 95%CI 0.85-0.95%) had HK. Their mean (SD) age was 60 (26) years and 58% were male. Of these, 884 had a second K+ measured within a median (IQR) of 5 (3-8) hours. Mortality and admission rates were higher in patients with HK vs. those with normal K+ (8.5% vs. 0.8%, P < 0.001 and 80% vs. 39%, P < 0.001, respectively). Mortality was lower in patients whose HK normalized compared with those whose K+ remained elevated (6.3% vs. 12.7%, P = 0.001). After adjusting for age, creatinine, comorbidities, and initial K+, normalization of K+ was associated with reduced mortality (OR 0.47, 95%CI 0.28 to 0.80). CONCLUSIONS: Normalization of K+ during the ED stay in patients with HK is associated with a 50% mortality reduction. Efforts to rapidly identify and treat HK in the ED are needed.

6.
Am J Emerg Med ; 2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31466912

RESUMO

BACKGROUND: Laceration closure is one of the most common procedures performed in the emergency department (ED). While sutures and staples have been the traditional wound closure device, topical skin adhesives (TSA) were introduced in the United States 20 years ago as a non-invasive alternative for simple, low-tension wounds. We determined which closure devices were used to close ED lacerations and explored patient and provider characteristics associated with choosing TSA. We also tested the hypothesis that use of TSA would be associated with shorter ED length of stay (LOS) than sutures/staples. METHODS: We extracted demographic and clinical data on all patients with a laceration from the publicly available website of the National Hospital Ambulatory Medical Care Survey for the years 2012-2015. This database is provided by the National Center for Health Statistics of the CDC. Based on weighted sampling, national estimates are made for all ED visits in the US. We determined the association between patient characteristics (age, sex, insurance type, geographic location, laceration site, type of ED provider) and use of TSA. We also compared ED LOS between patients whose wounds were closed with TSA or sutures/staples using the t-test and a linear regression model. RESULTS: There were an estimated 540 million ED patient visits, and 26.1 million patients (4.8%) had at least one laceration. Of the 15.4 million patients with a single laceration, 9.2 million were closed with either sutures/staples (7.2 million), TSA (1.5 million), or both (0.5 million). Mean (SE) age was 30 (1) years, 63% were male and 42% were under age 18 years. Lacerations were on the upper extremity (42%), face (30%), lower extremity (14%) and scalp (8%). Of patients with a single laceration closed with either TSA or sutures/staples, use of TSA did not differ by age, sex, year, geographic location or wound site. ED LOS was significantly shorter in patients whose wounds were closed with TSA (101 ±â€¯7 vs. 136 ±â€¯4 min; P < 0.001). After adjusting for potential confounding variables, use of TSA was associated with a 26 (95% CI 9-44) minute shorter ED LOS (P = 0.004) then sutures/staples. CONCLUSION: Topical skin adhesives are used in about 1 of 4 wound closures in the ED. Use of TSA did not differ based on demographic characteristics or wound site. Use of TSA is associated with a shorter ED LOS than sutures/staples.

7.
Am J Emerg Med ; 2019 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-31345594

RESUMO

BACKGROUND: A patient's vital signs are all inextricably interrelated, and together provide critical information regarding hemodynamic and physiological status. Yet, the precise relationship between body temperature (T) and heart rate (HR) in adults remains a fundamental gap in our knowledge. METHODS: We performed a retrospective secondary analysis of (1) electronic medical records from a large academic center (annual ED census of 110,000) and (2) the National Hospital Ambulatory Medical Care Survey (NHAMCS), a large CDC-sponsored weighted sample of U.S. EDs and our own large tertiary care ED, extracting demographic and clinical data including vital signs. RESULTS: We included 8715 local ED visits and approximately 123.3 million estimated national adult ED visits. Mean T was 36.9 °C, and 5.2% of patients had a T over 38 °C. Mean (SD) HR was 93.3 bpm, 28% had a HR over 100 bpm. Males had significantly lower HR than females (coefficient -1.6, 95%CI -2.4 to -0.8), while age was negatively associated with HR (coefficient -0.08, 95%CI -0.10 to -0.06). For national data, an increase of 1 °C in T corresponded to an increase in HR of 7.2 bpm (95%CI 6.2 to 8.3). After adjusting for age and gender, a 1 °C increase in T corresponded to a mean (95%CI) 10.4 (9.5-11.4) and 6.9 (5.9-7.8) increase in HR locally and nationally, respectively. CONCLUSIONS: Among adult ED patients nationally, for every increase in T of 1 °C, the HR increases by approximately 7 bpm.

8.
JAMA Netw Open ; 2(4): e192662, 2019 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-31002327

RESUMO

Importance: The US Patient Protection and Affordable Care Act of 2010 (ACA) was enacted in 2010 with several provisions that targeted reducing numbers of uninsured Americans. Objective: To assess the numbers and proportion of emergency department (ED) visits (2006-2016) and hospital discharges (2006-2016) by uninsured patients, focusing on the 2014 ACA insurance reforms (Medicaid expansion, individual mandate, and private insurance exchanges). Design, Setting, and Participants: Cross-sectional study of visitors to US EDs and patients discharged from US hospitals using National Hospital Ambulatory Care Survey data and Healthcare Cost and Utilization Project data, respectively, from 2006 to 2016. Data analysis took place in February 2019. Main Outcomes and Measures: Numbers and proportions of total and uninsured ED visits and hospital discharges. Simple descriptive statistics and interrupted time-series analysis were used to assess changes in uninsured visits over time and after the implementation of insurance provisions in 2014. Results: There were an estimated 1.4 billion US ED visits from 2006 to 2016 and 405 million hospital discharges from 2006 to 2016. Over the study period, ED visits increased by 2.3 million per year, while hospital discharges decreased from approximately 38 million per year prior to 2009 to approximately 36 million per year after, with no clear decrease after 2013. Proportions of uninsured ED visits were largely unchanged from 2006 (16%) until 2013 (14%) (-0.2 percentage point per year; 95% CI, -0.46 to -0.01 percentage point; P = .11) but then decreased by 2.1 percentage points per year from 2014 to 2016 (95% CI, -4.3 to -1.8 percentage points; P = .003), with uninsured visits composing 8% of the total in 2016. For patients aged 18 to 64 years, uninsured ED visits declined from approximately 20% from 2006 through 2013 to 11% in 2016 (3.1% decrease per year after 2013; 95% CI, -4.3 to -1.8 percentage points; P = .003). The proportion of hospital discharges by uninsured patients remained steady at approximately 6% from 2006 to 2013, then declined to 5% in 2014 and 4% in 2016. Similar changes were seen for patients aged 18 to 64 years, with a decrease in hospital discharges from 10% to 7% over the study period. Conclusions and Relevance: Proportions of ED visits and hospital discharges by uninsured patients decreased considerably after the implementation of the 2014 ACA insurance provisions. Despite these changes, approximately 1 in 10 ED visits and 1 in 20 hospital discharges were made by uninsured individuals in 2014 to 2016. This suggests that continued attention is needed to address the lack of insurance in US hospital visits, particularly among people aged 18 to 64 years who have less access to government-sponsored insurance.

9.
Wound Repair Regen ; 27(4): 426-430, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30843296

RESUMO

Transplantation of human xenografts onto immunocompromised mice is a powerful research tool for studying wound healing. However, differences in healing between humans and mice and their small size limit this model. We determined whether human cadaver skin xenografts transplanted onto pigs with severe combined immune deficiency (SCID) would survive and not be rejected. Meshed (1:1.5), cryopreserved human cadaver skin was transplanted onto 10 partial thickness dermatome wounds in each of two normal domestic pigs and two SCID pigs. Autografts (n = 2/animal) from the four animals were used as controls. In normal pigs, all autografts were engrafted and healed with a minimal, if any, inflammation and scarring. All human xenografts were rejected by the normal pigs within 5-11 days and associated with an intense T-cell inflammatory response. In contrast, both autografts and xenografts were engrafted and survived the 28-day study in the SCID pigs with a minimal inflammation and no gross scarring.

10.
J Thromb Haemost ; 17(5): 720-736, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30851227

RESUMO

Pulmonary embolism (PE) is the most feared clinical presentation of venous thromboembolism (VTE). Patients with PE have traditionally been treated in hospital; however, many are at low risk of adverse outcomes and current guidelines suggest outpatient treatment as an option. Outpatient treatment of PE offers several advantages, including reduced risk of hospital-acquired conditions and potential cost savings. Despite this, patients with low-risk PE are still frequently hospitalized for treatment. This narrative review summarizes current guideline recommendations for the identification of patients with low-risk PE who are potentially suitable for outpatient treatment, using prognostic assessment tools (e.g. the Pulmonary Embolism Severity Index [PESI] and simplified PESI) and clinical exclusion criteria (e.g. Hestia criteria) alone or in combination with additional cardiac assessments. Treatment options are discussed along with recommendations for the follow-up of patients managed in the non-hospital environment. The available data on outpatient treatment of PE are summarized, including details on patient selection, anticoagulant choice, and short-term outcomes in each study. Accumulating evidence suggests that outcomes in patients with low-risk PE treated as outpatients are at least as good as, if not better than, those of patients treated in the hospital. With mounting pressures on health care systems worldwide, increasing the proportion of patients with PE treated as outpatients has the potential to reduce health care burdens associated with VTE.

11.
Burns ; 45(2): 348-353, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30686696

RESUMO

INTRODUCTION: Itch after burn injury causes significant distress to patients and can hamper functional recovery. Itching can persist on a time scale ranging from several weeks to even years after injury. In this study, we sought to determine predictors of itching after burn injury. METHODS: We compared itch and pain severity among patients included in a burn registry at a level 1 trauma center. Both itch and pain severity was based on a 5-point scale. ANOVA, chi-squared, and multivariate analyses were performed to determine predictors of itch and pain severity. RESULTS: Of the 1159 patients enrolled in the registry, 58% were male and 42% female, with a median age (IQR) of 27 (8-47) years. Most patients were diagnosed with 2nd degree superficial (41%) or deep (43%) burns. Upper extremities were the most common location of burn injury (59%), followed by lower extremities (31%), trunk (22%), and face/neck (20%). More than half (53%) of enrolled patients reported itching, ranging from minimal (19%) to severe (7%) itching. Multivariate analyses revealed age, sex (female), extent of burn injuries, and location (face/neck) to be predictors of itch after burn. Predictors of pain after burn were slightly different: age, extent of burn, and depth of burn. CONCLUSION: Pain and itch after burn injuries are predicted by slightly different variables, presumably secondary to different underlying mechanisms. We conclude that age, sex (female), extent of burn injuries (total body surface area %), and injuries to the face/neck predict itching of greater severity. Patients with burn injuries that match these parameters would require greater care and closer follow up to reduce itching after healing.


Assuntos
Queimaduras/epidemiologia , Dor/epidemiologia , Prurido/epidemiologia , Adolescente , Adulto , Superfície Corporal , Queimaduras/complicações , Queimaduras/fisiopatologia , Criança , Traumatismos Faciais/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Dor/etiologia , Dor/fisiopatologia , Medição da Dor , Prurido/etiologia , Prurido/fisiopatologia , Fatores Sexuais , Índices de Gravidade do Trauma , Adulto Jovem
12.
Am J Emerg Med ; 37(4): 730-732, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30612779

RESUMO

BACKGROUND: Public awareness of the opioid epidemic is increasing nationally, emphasizing the need to develop methods to reduce opioid use. We determined patient preference for analgesics before and after a brief educational intervention informing them of the risks and benefits of opioids versus non-steroidal anti-inflammatory drugs (NSAID's). We hypothesized 50% of patients would prefer opioids pre-intervention and that this would be reduced by the intervention by at least 15%. METHODS: Study Design-Before and after study. Setting-Suburban ED with annual census of 110,000. Patients-English-speaking adult ED patients with acute musculoskeletal pain. Interventions-An anonymous survey was administered by an investigator not involved in the patient's clinical care prior to physician evaluation, before and after a video describing the risks and benefits of opioids versus NSAID's. Patients were asked if they desired analgesics. Data Analysis-Descriptive statistics were used to summarize the data. Univariate analysis and logistic regression were used to predict patient demographics and pain characteristics associated with desire for analgesics. RESULTS: Of all 94 patients, 48 (51% [95% CI 41-62%]) desired an analgesic pre-intervention. Of these 48 patients, 10 (11% [5-19%]) specifically preferred an opioid. Of the 10 patients who preferred an opioid pre-intervention, one had no preference for analgesic post-intervention. CONCLUSIONS: Many adult ED patients with acute musculoskeletal pain do not desire any analgesics and few specifically prefer opioids. This knowledge can prove helpful to ED physicians across the country in discussing pain management options with patients as we attempt to combat the opioid epidemic.


Assuntos
Analgésicos Opioides/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Dor Musculoesquelética/tratamento farmacológico , Educação de Pacientes como Assunto/métodos , Preferência do Paciente , Dor Aguda/tratamento farmacológico , Adulto , Serviço Hospitalar de Emergência , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , New York , Manejo da Dor/métodos , Gravação em Vídeo
13.
Am J Emerg Med ; 37(1): 33-37, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29703562

RESUMO

OBJECTIVES: There is growing evidence that venous thromboembolism (VTE) patients with distal clots (distal calf deep vein thrombosis [DVT] and sub-segmental pulmonary embolism [PE]) may not routinely benefit from anticoagulation. We compared the D-dimer levels in VTE patients with distal and proximal clots. METHODS: We conducted a multinational, prospective observational study of low-to-intermediate risk adult patients presenting to the emergency department (ED) with suspected VTE. Patients were classified as distal (calf DVT or sub-segmental PE) or proximal (proximal DVT or non-sub-segmental PE) clot groups and compared with univariate and multivariate analyses. RESULTS: Of 1752 patients with suspected DVT, 1561 (89.1%) had no DVT, 78 (4.4%) had a distal calf DVT, and 113 (6.4%) had a proximal DVT. DVT patients with proximal clots had higher D-dimer levels (3760 vs. 1670 mg/dL) than with distal clots. Sensitivity and negative predictive value (NPV) for proximal DVT at an optimal D-dimer cutoff of 5770 mg/dL were 40.7% and 52.1% respectively. Of 1834 patients with suspected PE, 1726 (94.1%) had no PE, 7 (0.4%) had isolated sub-segmental PE, and 101 (5.5%) had non-sub-segmental PE. PE patients with proximal clots had higher D-dimer levels (4170 vs. 2520 mg/dL) than those with distal clots. Sensitivity and NPV for proximal PE at an optimal D-dimer cutoff of 3499 mg/dL were 57.4% and 10.4% respectively. CONCLUSIONS: VTE patients with proximal clots had higher D-dimer levels than patients with distal clots. However, D-dimer levels cannot be used alone to discriminate between VTE patients with distal or proximal clots.


Assuntos
Anticoagulantes/uso terapêutico , Serviço Hospitalar de Emergência , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Embolia Pulmonar/metabolismo , Tromboembolia Venosa/metabolismo , Adulto , Idoso , Biomarcadores/metabolismo , Estado Terminal , Processamento Eletrônico de Dados , Feminino , Testes de Hemaglutinação , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/fisiopatologia , Sensibilidade e Especificidade , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/fisiopatologia
15.
Am J Emerg Med ; 37(6): 1085-1090, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30177267

RESUMO

OBJECTIVES: Emergency department (ED) visits for dental pain and low back pain (LBP) are common. Many such patients have severe pain and receive opioids. Increased opioid-related deaths has led to efforts to reduce opioid prescriptions. We compared recent trends in use of analgesics and opioids in the ED and at discharge among patients with dental or LBP. METHODS: We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) of patients with dental pain or LBP from 2010 to 2015. We performed univariate and multivariate analyses exploring the association between pain location and use of analgesics and opioids controlling for age, gender, and pain severity. RESULTS: There were an estimated 16 and 49 million patient visits for dental and LBP, respectively. Prescription of opioids at discharge decreased from 59% to 50% (p = 0.02) in dental and 46% to 39% in LBP patients (p = 0.09). Compared to patients with LBP, patients with dental pain were less likely to receive analgesics (OR 0.65, 95% CI, 0.57-0.74) or opioids (OR 0.51, 95% CI, 0.44-0.59) while in the ED. In contrast, dental pain patients were more likely to have analgesics (OR 1.32, 95% CI, 1.16-1.51) or opioids (OR 1.65, 95% CI, 1.47-1.85) prescribed at the time of ED discharge than patients with LBP. CONCLUSIONS: Prescription of opioids decreased for ED dental patients. While less likely to receive analgesics and opioids in the ED, patients with dental pain were more likely to be prescribed analgesics and opioids at the time of ED discharge than those with LBP.


Assuntos
Analgésicos Opioides/uso terapêutico , Assistência Odontológica/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Dor Lombar/tratamento farmacológico , Adolescente , Adulto , Idoso , Analgésicos/uso terapêutico , Criança , Pré-Escolar , Assistência Odontológica/métodos , Assistência Odontológica/estatística & dados numéricos , Prescrições de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Feminino , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Dor Lombar/epidemiologia , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Padrões de Prática Médica/tendências
16.
J Emerg Med ; 55(6): 741-750, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30391144

RESUMO

BACKGROUND: Contemporary emergency department (ED) standard-of-care treatment of hyperkalemia is poorly described. OBJECTIVE: Our aim was to determine the treatment patterns of hyperkalemia management in the ED. METHODS: This multicenter, prospective, observational study evaluated patients aged ≥ 18 years with hyperkalemia (potassium [K+] level ≥ 5.5 mmol/L) in the ED from October 25, 2015 to March 30, 2016. K+-lowering therapies and K+ were documented at 0.5, 1, 2, and 4 h after initial ED treatment. The primary end point was change in K+ over 4 h. RESULTS: Overall, 203 patients were enrolled at 14 U.S.-based sites. The initial median K+ was 6.3 (interquartile range [IQR] 5.7-6.8) mmol/L and median time to treatment was 2.7 (IQR 1.9-3.5) h post-ED arrival. Insulin/glucose (n = 130; 64%) was frequently used to treat hyperkalemia; overall, 43 different treatment combinations were employed within the first 4 h. Within 4 h, the median K+ for patients treated with medications alone decreased from 6.3 (IQR, 5.8-6.8) mmol/L to 5.3 (4.8-5.7) mmol/L, while that for patients treated with dialysis decreased from 6.2 (IQR 6.0-6.6) mmol/L to 3.8 (IQR 3.6-4.2) mmol/L. Hypoglycemia occurred in 6% of patients overall and in 17% of patients with K+ > 7.0 mmol/L. Hyperkalemia-related electrocardiogram changes were observed in 23% of all patients; 45% of patients with K+ > 7.0 mmol/L had peaked T waves or widened QRS. Overall, 79% were hospitalized; 3 patients died. CONCLUSIONS: Hyperkalemia practice patterns vary considerably and, although treatment effectively lowered K+, only dialysis normalized median K+ within 4 h.


Assuntos
Serviço Hospitalar de Emergência , Hiperpotassemia/terapia , Idoso , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tempo para o Tratamento , Resultado do Tratamento , Estados Unidos
17.
Am J Emerg Med ; 36(12): 2254-2259, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30322665

RESUMO

BACKGROUND: Speckle tracking echocardiography (STE) is a novel technology that measures regional wall-motion abnormalities that may speed diagnosis and intervention of acute coronary occlusion in Emergency Department (ED) patients with non-ST elevation ACS (NSTE-ACS). STE provides an objective measurement of myocardial strain that is superior to visual assessment of wall motion when performed as part of a point-of-care (POC) echocardiogram. We determined the feasibility and preliminary accuracy of POC STE operated by emergency providers when compared to comprehensive echocardiography or final diagnosis of ACS. METHODS: We retrospectively reviewed 187 emergency provider POC echocardiograms with STE from 7/2014-5/2016 for suspected ACS at a large academic trauma center. Feasibility of POC STE was determined by calculating the percentage of complete exams (adequate apical 4-chamber and parasternal short axis views) out of all STE exams. We then used two different criterion standards for calculating diagnostic accuracy of STE: comprehensive echocardiograms with wall motion abnormalities or formal diagnosis of ACS based on elevated cardiac troponins, unstable angina, percutaneous coronary intervention, or coronary artery stenosis >70% on catheterization. RESULTS: Of 187 STE studies performed, 75 (40%) were considered complete. Ultrasound-experienced providers had higher rates of complete exams (65% vs. 35%, P = 0.01). 16 of 75 exams (21%) were positive for myocardial strain, and of these 16 (100%) were admitted, 12 (75%) had positive troponins, 6 (46%) had positive comprehensive echocardiograms, and 3 (19%) had PCI or >70% stenotic lesion on catheterization. Compared with comprehensive echocardiography, POC STE had 35% sensitivity, 70% specificity, 46% positive predictive value (PPV), and 59% negative predictive value (NPV). Compared with formal diagnosis of ACS, POC STE had 29% sensitivity, 88% specificity, 75% positive predictive value (PPV), and 51% negative predictive value (NPV). CONCLUSION: STE is a potentially feasible adjunct to standard bedside echocardiography in ED patients with suspected ACS when operated by experienced ultrasound-trained physicians in the ED. This data shows STE performed by emergency providers is not yet sensitive enough alone to diagnose ACS, and has low accuracy when compared to comprehensive echocardiography. However, the PPV and specificity improve when performed by expert ultrasound-trained providers. STE should be considered for inclusion in the Emergency Ultrasound Fellowship curriculum.


Assuntos
Ecocardiografia/métodos , Serviço Hospitalar de Emergência , Cardiopatias/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto Jovem
18.
Burns ; 44(6): 1427-1432, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29895403

RESUMO

OBJECTIVES: A major goal of burn management is to reduce the progression of necrosis in the zone of ischemia surrounding the central zone of necrosis. A rat comb burn model is often used to assess the progression of necrosis in the zone of ischemia. We compared various combinations of naproxen [NPX], N-acetyl cysteine [NAC], and tadalafil [TD] (a phosphodiesterase-5 inhibitor used as a vasodilator to treat erectile dysfunction) in a rat comb burn model to determine their effects on injury progression. METHODS: We created two comb burns on the backs of 40 anesthetized Sprague-Dawley rats using a brass comb with four rectangular prongs preheated in boiling water and applied for 30s, resulting in four rectangular 10×20mm full-thickness burns separated by three 5×20mm unburned interspaces, representing the ischemic zones. We randomized five animals each to daily oral gavage with TD (1mg/kg), NPX (10mg/kg), NAC (500mg/kg), NAC+NPX, TD+NPX, TD+NAC, TD+NPX+NAC, or normal saline [NS]. Wounds were observed daily for gross evidence of necrosis in the unburned interspaces and full-thickness biopsies from the interspaces were evaluated with Hematoxylin & Eosin seven days after injury for histological evidence of necrosis. RESULTS: The percentages of interspaces with histological evidence of necrosis at day seven were TD-40%, NPX-93%, NAC-97%, NS-87%, TD+NPX-50%, TD+NAC-40%, TD+NPX+NAC-33%, and NPX+NAC-60% (P<0.001). Repeated measures ANOVA demonstrated reduced gross percentage of interspace area undergoing necrosis in all groups that included TD, compared with all groups not including TD (P<0.001). There were no differences among the various treatments within the groups that did or did not include TD. CONCLUSIONS: Daily oral therapy with tadalafil reduces necrosis in the unburned interspaces compared with naproxen, NAC, or their combination in a rat comb burn model. Addition of naproxen or NAC to tadalafil does not further reduce injury progression.


Assuntos
Queimaduras/patologia , Isquemia/patologia , Pele/efeitos dos fármacos , Tadalafila/farmacologia , Vasodilatadores/farmacologia , Acetilcisteína/farmacologia , Animais , Anti-Inflamatórios não Esteroides/farmacologia , Modelos Animais de Doenças , Progressão da Doença , Depuradores de Radicais Livres/farmacologia , Naproxeno/farmacologia , Necrose , Distribuição Aleatória , Ratos , Ratos Sprague-Dawley , Pele/irrigação sanguínea , Pele/patologia
19.
J Emerg Med ; 55(2): 172-178, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29887410

RESUMO

BACKGROUND: Core laboratory testing may increase length of stay and delay care. OBJECTIVES: We compared length of emergency department (ED) care in patients receiving point-of-care testing (POCT) at triage vs. traditional core laboratory testing. METHODS: We conducted a prospective, case-controlled trial of adult patients with prespecified conditions requiring laboratory testing and had POCT performed by a nurse after triage for: a basic metabolic panel, troponin I, lactate, INR (i-STAT System), urinalysis (Beckman Coulter Icon), or urine pregnancy test. Study patients were matched with controls based on clinical condition, gender, age, and time to be seen. Groups were compared with Wilcoxon rank-sum or Fisher's exact tests. RESULTS: We matched 52 POCT study patients with 52 controls. Groups were similar in age, gender, clinical condition, time to be seen by a physician (3.3 h, 95% confidence interval [CI] 2.2-4.4, vs. 3.1 h, 95% CI 2.2-4.5 h, in POCT and control patients, respectively; p = 0.84), use of imaging, and disposition. Of 52 study patients, 3 (5.8%, 95% CI 2.0-15.9) were immediately transferred to the critical care area to be urgently seen by an emergency physician. POCT patients had a significantly shorter median (interquartile range [IQR]) ED care time than matched controls (7.6, 95% CI 5.1-9.5 vs. 8.5, 6.2-11.3 h, respectively; p = 0.015). Median [IQR] ED length of stay was similar in study patients and controls (9.6, 95% CI 7.9-14.5 vs. 12.5, 8.2-21.2 h, respectively; p = 0.15). CONCLUSIONS: Among stable adult patients presenting to the ED with one of the prespecified conditions, early POCT at triage, compared with traditional core laboratory testing after evaluation by an ED provider, reduced ED care time by approximately 1 h.


Assuntos
Tempo de Internação/estatística & dados numéricos , Fatores de Tempo , Triagem/normas , Adulto , Idoso , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Imediatos , Estudos Prospectivos , Triagem/métodos , Triagem/estatística & dados numéricos
20.
Acad Emerg Med ; 25(9): 995-1003, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29757489

RESUMO

BACKGROUND: Hospitalization for low-risk pulmonary embolism (PE) is common, expensive, and of questionable benefit. OBJECTIVE: The objective was to determine if low-risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC). METHODS: Multicenter, open-label randomized trial in low-risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90-day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality. RESULTS: Of 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of -28.8 hours (95% confidence interval [CI] = -42.55 to -15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = -46.97 to -3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = -0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = -$2,999 to -$2,151). CONCLUSIONS: Low-risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.


Assuntos
Inibidores do Fator Xa/uso terapêutico , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Embolia Pulmonar/tratamento farmacológico , Rivaroxabana/uso terapêutico , Adulto , Idoso , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Padrão de Cuidado/economia , Adulto Jovem
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