Journal of Emergency Medicine最新文献

{"title":"Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?","authors":"","doi":"10.1016/j.jemermed.2024.05.007","DOIUrl":"10.1016/j.jemermed.2024.05.007","url":null,"abstract":"<div><h3>Background</h3><p>Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications.</p></div><div><h3>Clinical Question</h3><p>Is phenobarbital an effective treatment for AWS?</p></div><div><h3>Evidence Review</h3><p>Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS.</p></div><div><h3>Conclusions</h3><p>Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141042711","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":"Left Ventricular Pseudoaneurysm","authors":"","doi":"10.1016/j.jemermed.2024.04.011","DOIUrl":"10.1016/j.jemermed.2024.04.011","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141041397","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 Best Practices in U.S. Emergency Medical Services Guidelines","authors":"","doi":"10.1016/j.jemermed.2024.04.005","DOIUrl":"10.1016/j.jemermed.2024.04.005","url":null,"abstract":"<div><h3>Background</h3><p>Exertional heat illnesses (EHIs), specifically exertional heat stroke (EHS), are a top cause of nonaccidental death among U.S. laborers. EHS management requires coordination between Emergency Medical Services (EMS) and workplace officials to implement cold water immersion (CWI) and cool first, transport second (CFTS).</p></div><div><h3>Objective</h3><p>The purpose of this article was to quantify and identify existing statewide EMS guidelines, determine whether statewide EHS guidelines improved outcomes for EHIs in laborers, and examine the odds of laborer EHS fatalities when best practices are present in EMS statewide guidelines.</p></div><div><h3>Methods</h3><p>The Paramedic Protocol Provider database and official EMS websites were examined to determine which U.S. states had statewide EMS guidelines and, for those with statewide guidelines, a two-way χ² analysis with associated odds ratios examined EHI outcomes. Statewide EMS guidelines underwent content analysis by three independent reviewers regarding EHS best practices. Significance was set <em>a priori</em> at <em>p</em> &lt; 0.05.</p></div><div><h3>Results</h3><p>Among 50 states, the District of Columbia, and Puerto Rico, 57.7% (n = 30) had statewide EMS guidelines and 42.3% (n = 22) did not. There was a significant association for EHI outcome for states recommending CWI as a cooling method vs. those that did not (χ²₁ = 3.336; <em>p</em> = 0.049). The odds of EHS deaths for laborers were 3.0 times higher if CWI was not included in the EMS guidelines. There was a significant association in EHI outcomes for states without CFTS (χ²₁ = 5.051; <em>p</em> = 0.017). The odds of laborers dying from EHS were 3.7 times higher in states without CFTS.</p></div><div><h3>Conclusions</h3><p>Laborers are 3.0 and 3.7 times less likely to die from EHS when statewide EMS guidelines include CWI and CFTS, respectively.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141030443","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":"Evaluation of the Efficacy and Safety of Nicardipine Versus Clevidipine for Blood Pressure Control in Hypertensive Crisis","authors":"","doi":"10.1016/j.jemermed.2024.04.006","DOIUrl":"10.1016/j.jemermed.2024.04.006","url":null,"abstract":"<div><h3>Background</h3><p>Hypertensive crisis is an acute increase in blood pressure &gt;180/120 mm Hg. A titratable antihypertensive agent is preferred to lower blood pressure acutely in a controlled way and prevent an abrupt overcorrection. Nicardipine and clevidipine are both dihydropyridine calcium channel blockers that provide unique benefits for blood pressure control.</p></div><div><h3>Objective</h3><p>The purpose of this study was to compare the efficacy and safety of nicardipine or clevidipine for blood pressure control in the setting of hypertensive crisis.</p></div><div><h3>Methods</h3><p>This was a single-center, retrospective cohort study. Eligible patients received either nicardipine or clevidipine for the treatment of hypertensive crisis. The primary outcome was achievement of 25% reduction in mean arterial pressure at 1 h. The secondary outcome was achievement of a systolic blood pressure (SBP) of &lt;160 mm Hg at 2–6 h from the start of the infusion.</p></div><div><h3>Results</h3><p>This study included a total of 156 patients, 74 in the nicardipine group and 82 in the clevidipine group. The SBP on admission and at the start of the infusion were similar between groups. There was no difference between groups in achieving a 25% reduction in mean arterial pressure at 1 h. Nicardipine achieved an SBP goal of &lt;160 mm Hg at 2–6 h significantly more often than the clevidipine group (89.2% vs. 73.2%; <em>p</em> = 0.011).</p></div><div><h3>Conclusions</h3><p>There is no difference between agents for initial blood pressure control in the treatment of hypertensive crisis. Nicardipine showed more sustained SBP control, with a lower risk of rebound hypertension and a significant cost savings compared with clevidipine.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141023620","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":"Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review","authors":"","doi":"10.1016/j.jemermed.2024.04.007","DOIUrl":"10.1016/j.jemermed.2024.04.007","url":null,"abstract":"<div><h3>Background</h3><p>Parenteral ketorolac<span> and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness.</span></p></div><div><h3>Study Objectives</h3><p>To evaluate the comparative effectiveness of IV acetaminophen<span> and parenteral ketorolac for analgesia in the prehospital setting.</span></p></div><div><h3>Methods</h3><p>We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain.</p></div><div><h3>Results</h3><p>Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was −1.9 (SD 2.4) for acetaminophen group and −2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] −0.16, 0.37; PSM: 0.15, 95% CI −0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI −0.35, 0.72; IPTW: 0.23, 95% CI −0.25, 0.71; PSM: −0.03, 95% CI −0.61, 0.54).</p></div><div><h3>Conclusions</h3><p>We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141029030","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 late career crisis in emergency medicine","authors":"","doi":"10.1016/j.jemermed.2024.04.010","DOIUrl":"10.1016/j.jemermed.2024.04.010","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.2,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924001380/pdfft?md5=608e5374541db36d94a62e83ea9f0c95&pid=1-s2.0-S0736467924001380-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141050279","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":"Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit","authors":"Zachary Boivin MD ,&nbsp;Zhayna Spooner MD ,&nbsp;Christina Jiang MS ,&nbsp;Kirstin Acus MD ,&nbsp;Christina Lu MD ,&nbsp;Trent She MD","doi":"10.1016/j.jemermed.2023.11.014","DOIUrl":"10.1016/j.jemermed.2023.11.014","url":null,"abstract":"<div><p><em><strong>Background</strong></em>: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.</p><p><strong><em>Case Report:</em></strong> An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination &lt; 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital.</p><p><strong><em>Why Should an Emergency Physician Be Aware of This?</em></strong> Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138569542","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":"Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults","authors":"Xavier Dubucs MD, MSC ,&nbsp;Éric Mercier MD, MSC ,&nbsp;Valérie Boucher MSC ,&nbsp;Samuel Lauzon ,&nbsp;Frederic Balen MD ,&nbsp;Sandrine Charpentier MD, PHD ,&nbsp;Marcel Emond MD, MSC","doi":"10.1016/j.jemermed.2024.01.005","DOIUrl":"10.1016/j.jemermed.2024.01.005","url":null,"abstract":"<div><h3>Background</h3><p>Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury.</p></div><div><h3>Objective</h3><p>This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall–related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages.</p></div><div><h3>Methods</h3><p>We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall–related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1–3), vulnerable-frail (CFS score 4–6), and severely frail (CFS score 7–9).</p></div><div><h3>Results</h3><p>A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4–16.8]; <em>p</em> = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44–3.45; <em>p</em> = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41–13.6; <em>p</em> = 0.34) in those considered severely frail.</p></div><div><h3>Conclusions</h3><p>This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924000076/pdfft?md5=5537b8c00800181d98729b35d0f0d7d4&pid=1-s2.0-S0736467924000076-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139509034","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":"Treatment of Anticholinergic Delirium with Oral Rivastigmine: A Case Report","authors":"Christopher Karousatos MD,&nbsp;Lauren Murphy MD","doi":"10.1016/j.jemermed.2024.03.017","DOIUrl":"10.1016/j.jemermed.2024.03.017","url":null,"abstract":"<div><h3>Background</h3><p>Anticholinergic toxicity is commonly encountered in the emergency department. However, the availability of physostigmine, a central acetylcholinesterase inhibitor used to reverse anticholinergic delirium, has been significantly limited due to national drug shortages in the United States. Several articles have explored the viability of rivastigmine as an alternative treatment in these patients.</p></div><div><h3>Case Report</h3><p>A 33-year-old man presented to the emergency department after a suspected suicide attempt. The patient was found with an empty bottle of diphenhydramine at the scene. On arrival, he was tachycardic and delirious, with dilated and nonreactive pupils and dry skin. As the clinical picture was highly suggestive of anticholinergic toxicity, the patient was treated with oral rivastigmine at a starting dose of 4.5 mg to reverse his anticholinergic delirium. Although a repeat dose was required, his delirium resolved without recurrence. Why Should an Emergency Physician Be Aware of This? Oral rivastigmine has been applied successfully here and in other case reports to reverse anticholinergic delirium with the benefit of prolonged agitation control. Emergency physicians may consider this medication in consultation with a specialist, with initial doses starting at 4.5–6 mg, if encountering anticholinergic delirium when physostigmine is not available.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140273468","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":"Methamphetamine Poisoning After \"Plugging\" Intentional Recreational Rectal Use","authors":"Amye Farag MD,&nbsp;Sean Patrick Nordt MDPharmD,&nbsp;Joshua Perese MD","doi":"10.1016/j.jemermed.2024.01.004","DOIUrl":"10.1016/j.jemermed.2024.01.004","url":null,"abstract":"<div><h3>Background</h3><p>Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum.</p></div><div><h3>Case Report</h3><p>A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>Rectal administration of methamphetamine is known as “plugging,” “booty bumping,” “keestering,” and “butt whacking.” The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139458274","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}