Journal of Emergency Medicine最新文献

{"title":"Comments on \"End-Tidal Oxygen as an Effective Noninvasive Measure of Preoxygenation During Rapid Sequence Intubation in the Emergency Department\"","authors":"Amiya Kumar Barik DM , Anju Gupta MD , Chitta Ranjan Mohanty MD , Rakesh Vadakkethil Radhakrishnan MSN","doi":"10.1016/j.jemermed.2024.11.004","DOIUrl":"10.1016/j.jemermed.2024.11.004","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"71 ","pages":"Pages 121-123"},"PeriodicalIF":1.2,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143808038","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exertional Heat Stroke: Are We Cool Enough? Retrospective Observational Study of Patients of Running Events","authors":"Nathalie Dollée MD ,&nbsp;Jelmer Alsma MD, PhD ,&nbsp;Rob Goedhart PhD ,&nbsp;Ankie Bultstra ,&nbsp;Juanita A. Haagsma PhD ,&nbsp;Amber E. Hoek MD, PhD","doi":"10.1016/j.jemermed.2024.11.002","DOIUrl":"10.1016/j.jemermed.2024.11.002","url":null,"abstract":"<div><h3>Background</h3><div>Early recognition and immediate cooling are paramount in the treatment for exertional heat stroke (EHS). The most effective method is cold water immersion, however, practicalities may limit its use in the prehospital setting. An alternative is rotating ice water–soaked towels, which requires fewer personnel, can be deployed quickly, and allows easier patient monitoring.</div></div><div><h3>Objective</h3><div>The authors aimed to investigate the effectiveness of treatment with rotating ice water–soaked towels for patients with EHS to reduce (tympanic) temperature to &lt; 104°F (40°C) within 30 min.</div></div><div><h3>Methods</h3><div>In this retrospective observational study, participants ≥18 years who received medical care at running events with distances between 2.6 mile (4.2 km) and 26.2 miles (42.195 km; i.e., a full marathon) between 2016 and 2019 were included. Primary outcome was the percentage of patients with EHS who reached a temperature &lt; 104°F (40°C) within 30 min by means of cooling with rotating ice water–soaked towels.</div></div><div><h3>Results</h3><div>A total of 374,534 runners participated in one of the running events in the study period, of whom 879 required medical attention. Forty-eight runners had a tympanic temperature ≥ 104°F (40°C), of whom 36 were classified as having EHS based on presence of neurologic symptoms. Median age of patients was 32.5 years and most were male (69%). All patients that were cooled reached temperature &lt; 104°F (40°C) within 30 min. The mean cooling rate was 0.22°F/min (95% CI 0.16–0.27; 0.12°C/min [95% CI 0.09–0.15]). None of the patients with EHS died.</div></div><div><h3>Conclusions</h3><div>All patients with EHS in our study reached a temperature of &lt; 104°F (40°C) within 30 min, which suggests rotating ice water–soaked towels could provide an effective and practical method of cooling in the prehospital setting.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"71 ","pages":"Pages 44-53"},"PeriodicalIF":1.2,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143531451","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reduced-Dose Tenecteplase in High-Risk Pulmonary Embolism","authors":"Jennifer Hammond PharmD ,&nbsp;Dean Cataldo DO ,&nbsp;Christopher Allison MD ,&nbsp;Seth Kelly MD, MBA","doi":"10.1016/j.jemermed.2024.10.011","DOIUrl":"10.1016/j.jemermed.2024.10.011","url":null,"abstract":"<div><h3>Background</h3><div>Pulmonary embolism (PE) is a venous thromboembolic disease occurring when thrombi detach and embolize to pulmonary arteries, causing substantial morbidity and mortality in older adults yearly. In patients experiencing hemodynamic compromise, systemically administered thrombolytic therapy followed by anticoagulation over anticoagulation alone is recommended for initial management.</div></div><div><h3>Case Report</h3><div>This report describes successful treatment of a patient over 90 years of age presenting to the Emergency Department with an acute, high-risk PE who received low-dose, systemically administered tenecteplase followed by systemic anticoagulation with unfractionated heparin. The patient was initiated on norepinephrine 0.5 µg/kg/min for hemodynamic support. They were administered a reduced dose of tenecteplase (17.5 mg or 0.37 mg/kg) bolus followed by unfractionated heparin and subsequent transfer to the medical intensive care unit. At 1 h post-tenecteplase, norepinephrine was decreased to 0.2 µg/kg/min. At 14 h post-tenecteplase, the norepinephrine requirement was minimal at 0.02 µg/kg/min and resolved with extubation 15 h post-tenecteplase. The patient did not develop any clinically significant bleeding and was discharged to an acute rehabilitation facility on hospital day 7.</div></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><div>Available evidence suggests positive outcomes and dosing guidance for low-dose alteplase for PE treatment, though at the time of this report the authors identified a gap in existing literature surrounding the same concept with reduced-dose tenecteplase. Further studies are needed to investigate this intervention further.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"71 ","pages":"Pages 67-70"},"PeriodicalIF":1.2,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143483239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Change of Pace: Modifying Pacemaker Settings in the Emergency Department as Emergency Physicians, A Case Report","authors":"Maritza Kelesis MD,&nbsp;Martin Huecker MD, FAAEM, FACEP,&nbsp;Robert Whitford MD, FAAEM","doi":"10.1016/j.jemermed.2024.10.012","DOIUrl":"10.1016/j.jemermed.2024.10.012","url":null,"abstract":"<div><h3>Background</h3><div>Pacemakers are implantable or external devices that send electrical impulses, allowing the heart to contract. Some common indications for permanent pacemaker placement include symptomatic bradycardia due to high-grade atrioventricular (AV) block, sick sinus syndrome, chronic bifascicular block, and postcardiac transplantation. Like all devices, pacemakers can malfunction or stop working entirely. We present a patient with an implantable pacemaker/cardioverter and defibrillator (ICD) displaying symptomatic failure to capture, and settings were adjusted in the emergency department (ED). Adjustment in the ED resolved the patient's symptoms and required no further interventions.</div></div><div><h3>Case Report</h3><div>An 82-year-old woman with atrial fibrillation, heart failure, and a Medtronic dual chamber pacer/ICD (Medtronic, Minneapolis, Minnesota) presented to the ED for complaints of weakness and lightheadedness. Emergency medical services noted intermittent bradycardia, hypotension, and decreased responsiveness. Electrocardiogram (ECG) revealed failure to capture. The Medtronic application was used to interrogate and reprogram the device. The settings were DDD at a rate of 60 beats/min with ventricular output of 4.5 millivolts (mV) and atrial output of 4.5 mV, which were changed to ventricular lead outputs from 4.5 mV to 8.0 mV and rate from 60 to 80 for additional cardiac output. After this adjustment, the bradycardia resolved, and ECG showed a successful AV-paced rhythm. Transcutaneous pacing was never required.</div></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><div>Adjustment of pacer settings in the ED to stabilize the critically ill patient is within the scope of the emergency physician. We can reduce stress to the patient and prevent hospitalizations. Pacemakers can become a tool to optimize treatment plans for an aging population in whom pacemakers are becoming more common.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"71 ","pages":"Pages 82-87"},"PeriodicalIF":1.2,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143476696","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Aortic Laceration From Posterior Rib Fractures After a Ground-Level Fall: A Case Report","authors":"Benjamin Travers MD,&nbsp;Laura Murphy MD","doi":"10.1016/j.jemermed.2024.09.020","DOIUrl":"10.1016/j.jemermed.2024.09.020","url":null,"abstract":"<div><h3>Background</h3><div>Rib fractures represent a common injury after blunt chest wall trauma with known complications including pneumothorax, hemothorax, pulmonary contusion, and pneumonia. This case report describes an emergency department patient with acute decompensation from aortic laceration as a rare complication of rib fractures. There are rare documented cases of this complication occurring in admitted patients with rib fractures, but this is one of the only cases that describes this complication occurring in a patient presenting to the emergency department.</div></div><div><h3>Case Report</h3><div>This case describes a patient who was found down at her home and presented to the emergency department in acute distress. She was found to have three left-sided posterior rib fractures, which had lacerated her thoracic aorta causing a large left hemothorax and acute decompensation. The patient was resuscitated in the emergency department followed by thoracic endovascular aortic repair in the operating room. The patient did well after surgical repair and was discharged from the hospital at her baseline mental and functional status.</div></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><div>It remains important to resuscitate an acutely ill patient based on history, physical examination, and vital signs. The key takeaway from this case report is that, although rare, aortic laceration remains a possible complication of posterior rib fractures in a patient who acutely decompensates.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 139-141"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143408694","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is There an Association Between Emergency Department Overcrowding and Emergency Medical Services Redirection?","authors":"Kurien Mathews MD,&nbsp;Mukund Mohan MD,&nbsp;Paul Barbara MD,&nbsp;Arsalan Shawl DO,&nbsp;Norman Ng DO,&nbsp;Joseph Basile MD,&nbsp;Barry Hahn MD,&nbsp;Amin Mohamadi MD","doi":"10.1016/j.jemermed.2024.09.011","DOIUrl":"10.1016/j.jemermed.2024.09.011","url":null,"abstract":"<div><h3>Background</h3><div>Emergency Medical Systems (EMS) has developed policies to manage patient flow. In New York City, these practices include both diversion and redirection. Currently, gaps in the literature exist regarding the correlation between emergency department (ED) operational metrics and EMS redirection triggers.</div></div><div><h3>Objectives</h3><div>This study analyzes the relationship between ED operational metrics and EMS redirection practices.</div></div><div><h3>Methods</h3><div>This single-center retrospective cohort analysis analyzed EMS patient transports from April 2021 to May 2022. Data on EMS redirection was obtained from Fire Department of New York (FDNY) notifications, and ED operational metrics were collected from the hospital's data repository. Metrics included ED length of stay, admission rates, and times from door-to-triage and door-to-room.</div></div><div><h3>Results</h3><div>During the study, 93,783 patient visits were recorded, with 22,734 (24%) transported by EMS. Redirection was activated on 250 days, predominantly on Mondays. A slight association was found between overall ED volume and redirection occurrences (OR 1.02), but no significant correlations were identified with other specific ED operational metrics.</div></div><div><h3>Conclusions</h3><div>Our findings indicate no substantial correlation between these practices and ED operational metrics. These results suggest a need for a paradigm shift toward more objective, data-driven measures to inform EMS redirection, ensuring decisions are grounded in the ED's actual operational capacity.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 80-86"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143457836","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Promethazine: A Review of Therapeutic Uses and Toxicity","authors":"Christina K. Le PharmD, BCPS ,&nbsp;Craig A. Stevens PharmD, BCPS ,&nbsp;Jung Hoon Park PharmD, BCPS, BCCCP ,&nbsp;Richard F. Clark MD","doi":"10.1016/j.jemermed.2024.09.013","DOIUrl":"10.1016/j.jemermed.2024.09.013","url":null,"abstract":"<div><h3>Background</h3><div>Promethazine was first approved in 1951 and has since been used as a treatment option for a variety of indications. A histamine H₁ receptor competitive antagonist with antihistaminic, sedative, anti-kinetotic, antiemetic, and antimuscarinic effects, promethazine is utilized for the treatment of nausea and vomiting, a common reason for emergency department (ED) visits.</div></div><div><h3>Objective</h3><div>This review of promethazine explores its pharmacology and history of toxicities, and discusses current recommendations from patient safety organizations, which implicate its role in therapy.</div></div><div><h3>Discussion</h3><div>Injectable promethazine utilization should take into consideration patient-specific factors, institutional policies, medication shortages of alternative agents, and the efficacy and toxicities of injectable promethazine itself. For decades, injectable promethazine has been associated with rare but serious limb-threatening adverse effects after extravasation or inadvertent intra-arterial injection. Patient safety organizations have called for hospitals to remove injectable promethazine from formularies, and the U.S. Food and Drug Administration acted in December of 2023 to change the product labeling, adding dilution and administration recommendations for intravenous administration and stating a preference for intramuscular administration.</div></div><div><h3>Conclusion</h3><div>Promethazine offers a suitable alternative antiemetic for use in the ED due to its distinct mechanism of action. Injectable promethazine, however, must be used with caution to minimize risk of serious patient harm in the event of intra-arterial or perivascular extravasation when given parenterally.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 127-133"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143414228","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ropivacaine and Dexamethasone Incompatibility: A Warning for Emergency Physicians","authors":"Chitta Ranjan Mohanty MD ,&nbsp;Amiya Kumar Barik DM ,&nbsp;Subhasree Das MD ,&nbsp;Rakesh Vadakkethil Radhakrishnan MSN","doi":"10.1016/j.jemermed.2024.09.004","DOIUrl":"10.1016/j.jemermed.2024.09.004","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 168-169"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143548467","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Basic is Better? An Assessment of National Outcomes in Prehospital Airway Management in Critical Acuity Pediatric Trauma","authors":"Laura F. Goodman MD, MPH ,&nbsp;Alice M. Martino MD ,&nbsp;John Schomberg PhD ,&nbsp;Saeed Awan MD ,&nbsp;Peter Yu MD, MPH ,&nbsp;Theodore Heyming MD ,&nbsp;Jeffry Nahmias MD, MHPE ,&nbsp;Yigit S. Guner MD, MS ,&nbsp;David Gibbs MD, MHCM","doi":"10.1016/j.jemermed.2024.08.016","DOIUrl":"10.1016/j.jemermed.2024.08.016","url":null,"abstract":"<div><h3>Background</h3><div>Consensus is lacking regarding prehospital airway management in pediatric trauma patients (PTPs).</div></div><div><h3>Objectives</h3><div>This retrospective study compared prehospital basic-airway procedures (B-AP) vs. advanced-AP (A-AP) among PTPs, comparing scene time, transport time, and improvement in acuity from scene to emergency department.</div></div><div><h3>Methods</h3><div>The 2020 National Emergency Medical Services Information System was used to study patients 1–18 years old with prehospital AP. A-AP were compared with B-AP using chi-square, Wilcoxon rank sum, multivariable logistic, and linear regression models in terms of improvement in acuity, and transport and scene times.</div></div><div><h3>Results</h3><div>The 3325 cases included 672 A-AP and 2653 B-AP; 39 esophageal combi- or dual lumen tubes, 48 laryngeal mask airways, and 585 orotracheal intubations. Overall failure rate: A-AP 8.77% vs B-AP 1.09% (<em>p</em> &lt; 0.0001). Adjusted models identified reduction in scene time for B-AP vs. A-AP (estimate: 4 min 51 s, 95% confidence interval 9 min, 49 s–6 s; <em>p</em> = 0.01). B-APs were associated with improved acuity (odds ratio 1.19, 95% confidence interval 1.11–1.27; <em>p</em> &lt; 0.001) after adjusting for Revised Trauma Score, provider type, urbanicity, time spent at scene, and demographic variables.</div></div><div><h3>Conclusion</h3><div>Prehospital B-APs were associated with shorter scene time and improvement in acuity compared with A-AP in PTPs. Variability in airway management practices across U.S. regions is high, leaving room for improvement in standardization of care and training.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 68-79"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143365093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization","authors":"Aaron J. Lacy MD ,&nbsp;Michael J. Kim MD ,&nbsp;James L. Li MD, M.Ed ,&nbsp;Alexander Croft MD ,&nbsp;Erin E. Kane MD, MHPE ,&nbsp;Jason C. Wagner MD ,&nbsp;Philip W. Walker MD ,&nbsp;Christine M. Brent MD ,&nbsp;Jeremy J. Brywczynski MD ,&nbsp;Amanda C. Mathews MD ,&nbsp;Brit Long MD ,&nbsp;Alex Koyfman MD ,&nbsp;Bridgette Svancarek MD","doi":"10.1016/j.jemermed.2024.08.018","DOIUrl":"10.1016/j.jemermed.2024.08.018","url":null,"abstract":"<div><h3>Background</h3><div>Definitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure.</div></div><div><h3>Objective</h3><div>Review and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies.</div></div><div><h3>Discussion</h3><div>Technical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of Emergency Medical Service (EMS) Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed.</div></div><div><h3>Conclusions</h3><div>By focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.</div></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"70 ","pages":"Pages 19-34"},"PeriodicalIF":1.2,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143365105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}