Journal of Emergency Medicine最新文献

{"title":"A Retrospective Cohort Study of Tranexamic Acid Administration for the Treatment of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema in the Emergency Department.","authors":"Michael Loewe, Eric Rowley, Joel Mosley, Benjamin Gibson, Michael Cerjance, Elizabeth Pearson, Greggory Davis","doi":"10.1016/j.jemermed.2024.10.001","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.10.001","url":null,"abstract":"<p><strong>Background: </strong>Treatment options for angiotensin-converting enzyme inhibitor-induced angioedema (ACEi-AE) are primarily limited to airway monitoring and protection with intubation. The efficacy of tranexamic acid (TXA) in this context remains poorly understood.</p><p><strong>Objective: </strong>Examine outcomes among patients treated with and without TXA for ACEi-AE.</p><p><strong>Methods: </strong>A retrospective cohort study conducted in two hospitals examined emergency department patients with suspected ACEi-AE from 2017 to 2021. Primary outcomes included intensive care unit (ICU) admission, intubation, days intubated, time to administration of TXA, surgical airway required, and death in patients that received TXA compared with those that did not.</p><p><strong>Results: </strong>Of 336 eligible patients, 37 received TXA and 299 did not. ICU admission rate was significantly higher in the TXA group (57%) vs. the no-TXA group (15%), odds ratio (OR) 7.61 (95% confidence interval [CI] 3.69-15.70). There were significantly more intubations in the TXA group (20%) vs. the no-TXA group (5.7%), OR 3.87 (95% CI 1.49-10.08). The median time to TXA administration was 51 min (interquartile range 34-131). The number of days intubated, surgical airway, and 30-day mortality were not significantly different in the TXA group compared with the no-TXA group.</p><p><strong>Conclusion: </strong>TXA use did not improve many of the clinical outcomes involved in the treatment of ACEi-AE. One interpretation of these results may be that TXA use was associated with patients who presented with more severe disease, as TXA use was up to the discretion of the treating physician. Randomized controlled trials are needed to clarify the efficacy of TXA use in ACEi-AE.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425422","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":"Incidence of Acute Kidney Injury After Exposure to Intravenous Contrast in Emergency Department Patients Presenting for Stroke.","authors":"Imran Faruqi, Terrell Caffery, Maddie Colter, Cameron Williams, Ashley Trent, Douglas Cushner, Jacob Nelson, Greggory Davis","doi":"10.1016/j.jemermed.2024.09.012","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.012","url":null,"abstract":"<p><strong>Background: </strong>Chronic kidney disease (CKD) is to be considered an independent risk factor for developing post-computed tomography (CT) acute kidney injury (AKI); however, current data are limited.</p><p><strong>Objectives: </strong>Examine the incidence of AKI after intravenous contrast exposure among patients with and without CKD.</p><p><strong>Methods: </strong>A single-center retrospective study examined patients that presented to the Emergency Department and activated the stroke protocol, which involved an immediate CT angiogram. Patients were subdivided into \"normal to mild\" (glomerular filtration rate [GFR] > 60 mL/min/1.73 m²), CKD III (GFR 30-60 mL/min/1.73 m²), and CKD IV (GFR < 30 mL/min/1.73 m²) groups. The primary outcome was the development of AKI. Patients already on dialysis were excluded.</p><p><strong>Results: </strong>Among the 794 patients identified, 452 (56.9%) were classified as \"normal to mild,\" 280 (35.3%) were classified as CKD III, and 62 (7.8%) were classified as CKD IV. Patients with normal GFR had a 2.4% incidence of developing AKI, those with CKD III had a 1.4% incidence, and patients with CKD IV had an 8.1% incidence of developing AKI. Overall, 2.5% of patients developed AKI. For CKD III vs. \"normal\" groups, odds ratio (OR) = 0.58 (95% confidence interval [CI] 0.16-1.72). For CKD IV vs. \"normal,\" OR = 3.52 (95% CI 1.07-10.05). Of those patients with CKD IV who had AKI, all saw improvement in their creatinine prior to discharge and none required renal replacement therapy.</p><p><strong>Conclusion: </strong>This study builds on the evidence demonstrating that patients with CKD III are likely at the same risk of developing post-CT AKI as those with normal renal function. Furthermore, the risk of developing post-CT AKI in CKD IV patients may be far lower than previously thought, was transient, and did not result in renal replacement therapy.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143374149","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":"Landmarks for Positioning and Local Anesthesia to Improve Success and Experience in Reduction of the Dislocated Temporomandibular Joint.","authors":"Akshay Govind, Stanley Onuegbu, Sahm Rafati, Phillip Harrison, David K Duong","doi":"10.1016/j.jemermed.2024.09.016","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.016","url":null,"abstract":"<p><strong>Background: </strong>Anterior dislocation of the temporomandibular joint (TMJ) occurs when the condylar head slips out of the glenoid fossa and is locked anterior to the articular eminence. Dislocation typically occurs in the setting of wide mouth opening and increased ligament flexibility, but trauma or anatomical variations of the condyle and articular eminence may contribute as well. In cases of muscle spasm following dislocation, local anesthetic, or sedation can be used to relieve muscle tension and reduce pain, thus facilitating successful TMJ reduction.</p><p><strong>Discussion: </strong>An overview of commonly used reduction techniques is presented, including anterior, posterior, and alternative approaches. This paper additionally describes an algorithm for positioning of the provider, the patient, and the room to optimize the vectors of force application during reduction of the anteriorly dislocated TMJ. Previously undescribed detail when using an intraoral, posterior approach is highlighted, with special attention paid to aligning the provider's elbows with the patient's maxillary molars. For adjunctive use of local anesthetic, providers can locate the joint space by first indentifying the root of the zygomatic arch and then redirecting the needle inferiorly to a depth of roughly 25 mm from the skin. Additionally, one can inject directly into the masseter and temporalis muscles. Procedural sedation may also be used, with an anecdotal preference for midazolam, fentanyl, and propofol.</p><p><strong>Conclusion: </strong>Multiple reduction techniques are compared, discussing the advantages and disadvantages of each. A novel decision-making algorithm is offered, detailing positioning, approach selection, use of local anesthesia, sedation, and aftercare instructions.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143408697","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":"Simultaneous Cases of Familial Hypokalemic Periodic Paralysis Induced by Illicit Injection of Betamethasone.","authors":"Brandon Chen, Christopher J Counts, Phillip Maresca, Howard A Greller, Mitchell J Heller","doi":"10.1016/j.jemermed.2024.09.021","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.021","url":null,"abstract":"<p><strong>Background: </strong>Periodic paralysis is a rare neuromuscular disorder characterized by episodes of painless muscle weakness. Hypokalemic periodic paralysis (HPP) is the most common subtype of periodic paralysis. HPP may be an acquired illness but, most often, it is associated with an inherited abnormality of calcium or sodium ion channels. Episodes of HPP can be triggered by multiple factors, most commonly strenuous exercise or consuming large amounts of carbohydrates. Other triggers include emotional factors, environmental factors, other dietary factors, toxins, and medicines. Hypokalemia may be due to potassium wasting or intracellular sequestration of potassium. When ordering potassium repletion, it is important to identify hypokalemia due to sequestration in order to avoid iatrogenic hyperkalemia.</p><p><strong>Case report: </strong>We report the cases of two brothers with previously undiagnosed familial HPP with flaccid paralysis of their limbs after receiving illicit intramuscular injections of betamethasone. Serum potassium concentrations were 1.6 and 1.9 mmol/L. Both ECGs demonstrated U-waves and the older brother's ECG demonstrated widening of the QRS. The brothers were treated with oral and intravenous potassium supplementation. After briefly becoming hyperkalemic, their serum potassium concentrations returned to normal, and their paralysis resolved within 24 hours. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hypokalemic periodic paralysis (HPP) is a rare condition with a unique pattern of signs and symptoms and numerous possible inciting factors. Although glucocorticoids are a known trigger for HPP, previous reports have been limited to iatrogenic cases and almost exclusively reported outside the United States and not in emergency department presentations. Emergency physicians should be alert for cases induced by illicit use of steroids, as well as iatrogenic cases. Prompt recognition of HPP and identification of its etiology from history, physical examination, and appropriate laboratory studies can expedite treatment, prevent iatrogenic hyperkalemia, promptly allay patient and clinician fears, and avoid wasteful use of laboratory and imaging resources.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143425490","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, Craig A Stevens, Jung Hoon Park, Richard F Clark","doi":"10.1016/j.jemermed.2024.09.013","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.013","url":null,"abstract":"<p><strong>Background: </strong>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.</p><p><strong>Objective: </strong>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.</p><p><strong>Discussion: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-09","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":"Hyperbaric Oxygen Therapy: An Evidence-Based Primer for Emergency Physicians.","authors":"Margot Samson, Michael Gottlieb, Christopher Logue, Daniel Popa","doi":"10.1016/j.jemermed.2024.09.009","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.009","url":null,"abstract":"<p><strong>Background: </strong>Hyperbaric medicine is a subspecialty that many emergency physicians may not encounter frequently in their daily practice. As such, we hope to provide a review, where we present an overview of hyperbaric oxygen therapy, complications from the therapy, and a description of how the treatments are administered. We also discuss seven emergency indications that may benefit from transfer to a hyperbaric facility for treatment.</p><p><strong>Objective of the review: </strong>Our aim is to provide an overview of hyperbaric oxygen therapy as it pertains to an emergency physician. We hope that this review will help emergency physicians identify conditions that may benefit from transfer to a hyperbaric facility.</p><p><strong>Discussion: </strong>We discuss seven emergency conditions that may benefit from transfer to a hyperbaric facility for management-decompression sickness, arterial gas embolism, central retinal artery occlusion, carbon monoxide poisoning, crush injury, necrotizing soft tissue infection, and symptomatic anemia. We also describe special considerations for how to transfer patients needing evaluation by a hyperbaric physician.</p><p><strong>Conclusions: </strong>This review aims to describe hyperbaric oxygen therapy, identify conditions that may benefit from treatment with hyperbaric oxygen, and discuss management of patients with those conditions as it pertains to an emergency physician.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143408695","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":"Woman with Recurrent Headaches.","authors":"Chad Stanley, Richard Newman, Farid Khasiyev, Cindy C Bitter","doi":"10.1016/j.jemermed.2024.09.014","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.014","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143374150","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":"Using Point-of-Care Ultrasound to Assess Gastrostomy Balloon Placement.","authors":"Nithin S Ravi, Rakesh D Mistry, Jonathan Orsborn, Mairead Dillon, Jeffrey Tutman, Kari Hayes, Carmelle Wallace, Jeremiah T Lowe, Tien Vu","doi":"10.1016/j.jemermed.2024.09.017","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.09.017","url":null,"abstract":"<p><strong>Background: </strong>Fluoroscopy is the gold standard for evaluation of gastrostomy tube (GT) placement, though it is costly and resource-intensive. Point-of-care ultrasound (POCUS) has potential as a low-risk alternative to confirm GT placement.</p><p><strong>Objective: </strong>To determine the diagnostic accuracy of POCUS for identification of correct gastrostomy balloon placement as compared to fluoroscopy.</p><p><strong>Methods: </strong>This was a prospective convenience sample of children presenting to interventional radiology for routine GT or gastrojejunal (GJ) tube exchange. Prior to exchange, POCUS operators scanned and interpreted ultrasound images for GT placement, followed by fluoroscopy. A blinded radiologist interpreted fluoroscopic studies. Diagnostic test characteristics, concordance with 95% confidence intervals, and interrater agreement (Cohen's Kappa) between POCUS and fluoroscopy were calculated.</p><p><strong>Results: </strong>Four (3%) of 118 evaluated GT balloons were displaced. Compared to fluoroscopy, novice POCUS assessment of GT/GJ balloon placement had a sensitivity of 87% (79%-92%), specificity of 25% (1%-81%), PPV of 97% (92%-99%), NPV of 6% (1%-30%), proportion agreement of 85%, (77%-91%) kappa 0.04. Expert POCUS interpretation exhibited sensitivity of 91% (84%, 96%), proportion agreement of 89% (82%-94%), kappa 0.09. pH testing had the highest sensitivity of 93% (85%, 97%), proportion of agreement 92% (84%-97%) and kappa 0.19.</p><p><strong>Conclusion: </strong>POCUS demonstrated a high sensitivity and concordance for GT/GJ balloon placement, with low interrater agreement with fluoroscopy. POCUS may not add additional clinical benefit in routine evaluation of GTs over current standards of care. However, POCUS may serve as a useful screening test in settings where fluoroscopy is unavailable or pH is unobtainable.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143414308","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":"American Academy of Emergency Medicine","authors":"","doi":"10.1016/S0736-4679(24)00309-3","DOIUrl":"10.1016/S0736-4679(24)00309-3","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 5","pages":"Pages e504-e505"},"PeriodicalIF":1.2,"publicationDate":"2024-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924003093/pdfft?md5=86cc054d0f0314e84f70d132911b8acb&pid=1-s2.0-S0736467924003093-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142241531","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}

{"title":"Impact of Prospective, System-Wide Intervention to Influence Opioid Prescribing Practices Among Patients with Back Pain.","authors":"Virgenal Owens, Meghan K Wally, Ziqing Yu, Daniel Leas, Rebecca Henson, Rachel B Seymour, Joseph R Hsu, Susan Odum","doi":"10.1016/j.jemermed.2024.08.013","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.08.013","url":null,"abstract":"<p><strong>Background: </strong>In response to the opioid epidemic, our multidisciplinary team designed and integrated an alert-based, clinical-decision support intervention which identifies patients at risk of opioid misuse based on five evidence-based risk factors (early refill of opioids/benzodiazepines; >2 ED/Urgent Care visits with onsite opioids; >3 prescriptions of opioids/benzodiazepines; prior overdose; and positive toxicology screen).</p><p><strong>Objective: </strong>To evaluate the impact of the intervention on prescribing decisions for back pain by measuring the percent of opioid prescriptions modified in response to the alert.</p><p><strong>Methods: </strong>A total of 93,192 adult patients presenting to the emergency department with complaints of back pain from 2017-2021 were included in this prospective, observational study. We calculated rates of \"decision influenced\" (modifying or canceling prescriptions) in response to the PRIMUM intervention and characterized patients, encounters, and prescriptions in this population.</p><p><strong>Results: </strong>The 30.2% of back pain patients received an opioid prescription. Among patients prescribed opioids, 18.6% had a risk factor. An alert fired in 6,501 (19.8%) encounters, and positive toxicology was the most common risk factor (52.1%). The prescriber decision was influenced in 430 of these encounters overall (6.6%) and was highest for three or more prescriptions in the past month (11.8%) and early refill (9.1%). Chronic patients were more likely to receive opioids.</p><p><strong>Conclusions: </strong>Roughly 1 in 3 patients presenting to the emergency department for back pain received an opioid. A clinical decision support intervention to identify patients at risk of opioid use disorder had a minimal influence on opioid prescribing decisions in this population.</p>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143370344","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}