American Journal of Emergency Medicine最新文献

{"title":"Maintaining use of the term ketamine toxicity.","authors":"Skyler Kessler, Bernard Weigel, Ross Ellison, Roy Gerona, Joshua Zimmerman, Michael Nelson","doi":"10.1016/j.ajem.2025.01.036","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.036","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"C. neoformans meningitis without pleocytosis, hyperproteinorrachia, and hypoglycorrhachia on cerebrospinal fluid studies.","authors":"Bradley Sheffield, Michelle Troendle","doi":"10.1016/j.ajem.2025.01.042","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.042","url":null,"abstract":"<p><p>Diagnosis of cryptococcal meningitis is typically aided through CSF analysis obtained via lumbar puncture (LP), revealing elevated WBCs, increased protein, decreased glucose, and increased opening pressure. While CSF culture confirms the diagnosis, it takes days, prompting reliance on these adjuncts. AIDS from Human Immunodeficiency Virus is less commonly diagnosed in the emergency setting due to advances in testing and treatment. This case highlights fungal meningitis in an undiagnosed AIDS patient, where positive CSF cryptococcal antigen enabled timely diagnosis despite normal CSF findings, emphasizing the importance of rapid diagnostic tests in high-risk patients even when CSF results appear normal. A 30-year-old male with no prior medical history presented with 3.5 weeks of nausea, vomiting, headache, and back pain. He showed signs of cachexia, photophobia, and neck stiffness. Initial CSF analyses were within normal limits for glucose, WBC, and protein, but cryptococcal antigen was positive. He was treated with amphotericin B and flucytosine. CSF cultures confirmed C. neoformans, and serial LPs monitored elevated opening pressures, requiring a VP shunt. The patient was diagnosed with AIDS (CD4 6 cells/mm³). This case underscores that C. neoformans can present with normal CSF studies, delaying diagnosis and treatment, highlighted by the fact that this patient went undiagnosed in the preceding 3.5 weeks. CSF cryptococcal antigen and opening pressure are critical diagnostic tools, enabling timely antifungal therapy. Given the high mortality rate, early empirical treatment is essential, especially in high-risk patients, even when CSF findings seem normal.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of the COVID-19 pandemic on emergency department utilization of initial fibrinolysis for the treatment of STEMI.","authors":"Whitney B Sussman, Conner E Johnson, Erin R Weeda","doi":"10.1016/j.ajem.2025.01.030","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.030","url":null,"abstract":"<p><strong>Objective: </strong>Fibrinolysis is generally considered an alternative to percutaneous coronary intervention (PCI) for ST-Segment Elevation Myocardial Infarction (STEMI) when PCI is not immediately feasible. The COVID-19 pandemic may have impacted the timeliness of PCI. We sought to compare the rate of fibrinolysis use before vs. during the COVID-19 pandemic in US emergency departments (EDs). Characteristics of patients and EDs with fibrinolysis use prior to vs. during the COVID-19 pandemic were also compared.</p><p><strong>Methods: </strong>We identified adult patients presenting to US EDs for STEMI using the Nationwide Emergency Department Sample (NEDS) database. The cohort was restricted to individuals receiving fibrinolysis. Patients were divided into two cohorts based on receipt of fibrinolysis during the pre-pandemic (April 2018-December 2019) and pandemic (April 2020-December 2021) time periods.</p><p><strong>Results: </strong>In the period prior to the COVID-19 pandemic, fibrinolysis use was identified in 1593 ED encounters, representing a rate of 24.5 per 1000 STEMI encounters in the database. In the COVID-19 pandemic period, fibrinolysis use was identified in 1700 encounters, representing a rate of 28.2 per 1000 STEMI encounters in the database. This corresponded to a rate difference of 3.7 per 1000 STEMI encounters (95 % confidence interval: 1.9-5.5, p < 0.001). Most ED and patient characteristics were similar prior to vs during the pandemic among included cohorts.</p><p><strong>Conclusions: </strong>Fibrinolytic therapy use increased, but only slightly, during the COVID-19 pandemic. This suggests that the healthcare system adapted quickly to changes during the pandemic in the setting of STEMI treatment.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"106-108"},"PeriodicalIF":2.7,"publicationDate":"2025-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143042814","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Erector spinae plane block for management of acute opioid withdrawal in the emergency department: A case report.","authors":"Richard J Gawel, Jeffrey A Kramer, Nova Panebianco, Michael Gottlieb, Frances S Shofer, Michael Shalaby","doi":"10.1016/j.ajem.2025.01.033","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.033","url":null,"abstract":"<p><strong>Background: </strong>Gastrointestinal symptoms of acute opioid withdrawal are distressing for patients and are often difficult to manage with conventional therapies. Insufficiently managed opioid withdrawal symptoms may lead patients to leave against medical advice, which can increase their risk of relapse and result in poor outcomes from untreated conditions. We assessed the impact of an erector spinae plane block on the acute gastrointestinal symptoms of opioid withdrawal.</p><p><strong>Case report: </strong>A 44-year-old woman with opioid use disorder presented to the ED with severe gastrointestinal symptoms of opioid withdrawal, refractory to parenteral opioid agonists and symptomatic treatment. She underwent an ultrasound-guided erector spinae plane block with 30 mL of 0.25 % bupivacaine which completely resolved her gastrointestinal symptoms.</p><p><strong>Conclusion: </strong>Through blockade of the sympathetic chain, the erector spinae plane block could provide targeted symptomatic relief for patients presenting with severe gastrointestinal symptoms of opioid withdrawal. Future research should seek to evaluate the efficacy observed in this case in larger patient populations.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030335","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is magnesium level significant in prognosis of geriatric patients admitted to the emergency department?","authors":"Dilber Üçöz Kocaşaban, Sertaç Güler","doi":"10.1016/j.ajem.2025.01.022","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.022","url":null,"abstract":"<p><strong>Aim: </strong>This study aims to evaluate the impact of serum magnesium (Mg) level on hospitalization and 28-day mortality in a nonspecific geriatric patient population.</p><p><strong>Method: </strong>This single-center retrospective and observational clinical study involved patients aged over 70 years who presented to the emergency department for any complaint. Those whose Mg levels were not assessed and those who presented due to trauma, treated in another hospital before coming to our hospital, presented in cardiopulmonary arrest, refused treatment and/or left the hospital without permission, and were referred to another hospital were excluded from this study. The patients were classified as having hypomagnesemia (≤1.7 mg/dL Mg), normomagnesemia (1.7-2.2 mg/dL), and hypermagnesemia (≥2.2 mg/dL). We assessed whether patients between these groups could provide data on hospitalization, discharge, and 28-day mortality.</p><p><strong>Results: </strong>The average age of the included patients was 77.11 ± 7.91 years. Of the patients, 1032 (55.3 %) were female. The incidence rates of hypomagnesemia, normomagnesemia, and hypermagnesemia significantly differed between the hospitalized and discharged patients (p < 0.01). In older patients, hypermagnesemia was associated with hospitalization. Moreover, a significant difference in Mg levels at 28 days was observed between the deceased patients and survivors (p < 0.001); hypermagnesemia was significantly more common among the deceased patients. The results of the univariate and multivariate regression analyses showed that hypermagnesemia was a significant factor for discharge at 28 days (p < 0.001).</p><p><strong>Conclusion: </strong>While hypomagnesemia is more manageable than hypermagnesemia, the latter is an important predictor of hospitalization and 28-day mortality in individuals over 70 years old.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"88-92"},"PeriodicalIF":2.7,"publicationDate":"2025-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143025631","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of trauma center designation level on survival in trauma during pregnancy: Observational study across US trauma centers.","authors":"Sarah Traboulsy, Joe Demian, Rana Bachir, Mazen El Sayed","doi":"10.1016/j.ajem.2025.01.029","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.029","url":null,"abstract":"<p><strong>Background: </strong>Trauma is the leading non obstetric cause of death in pregnant women. Pregnancy above 20 weeks falls under special considerations group in the Center for Disease Control and Prevention (CDC) field triage criteria. Trauma centers' designation level in the United States is based on available resources for care.</p><p><strong>Aim: </strong>In this study, we examine the association between trauma center designation level and survival of pregnant patients presenting to the Emergency Department (ED) after a traumatic injury.</p><p><strong>Methods: </strong>This retrospective observational study included all pregnant women of reproductive age (16 years and above) who experienced any form of trauma and were registered in the National Trauma Data Bank 2020 dataset. Descriptive analysis was carried out. All variables were stratified by the trauma designation levels. Firth logistic regression was conducted to examine the association between trauma designation levels and survival to hospital discharge after controlling for all potential confounding factors.</p><p><strong>Results: </strong>A total of 1612 patients were included in this study. The average age was 27.2 (±6.9 years). Most patients were taken to level I (58.3 %) and II (33.9 %) centers. Overall survival of patients after pregnancy trauma was 97.2 %. After adjusting for confounders, patients taken to level II and III trauma centers had similar survival to hospital discharge compared with those taken to level I centers [OR = 2.561, 95 % CI: 0.644-10.182 and OR = 4.886, 95 % CI: 0.584-40.862 respectively].</p><p><strong>Conclusion: </strong>In this study, trauma center designation level did not impact survival of pregnant patients sustaining injuries. This provides further evidence that the CDC's field triage guidelines, including their specific considerations for pregnant patients are accurate and that the current practice seems to be effective.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"71-77"},"PeriodicalIF":2.7,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016991","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"ED observation unit-based delayed comfort care pathway for ED patients on life support.","authors":"Jiayin Sun, Melissa D'Souza, Michael Losak, Natalie Htet, Crystal Miles-Threatt, Tsuyoshi Mitarai","doi":"10.1016/j.ajem.2025.01.031","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.031","url":null,"abstract":"<p><strong>Background: </strong>Critically ill ED patients on life support may undergo transition to comfort care as decided by the surrogate decision maker. When several hours are needed for loved ones to arrive and say farewell before initiating comfort care (\"delayed comfort care\"), these patients require prolonged ED stays or costly intensive care unit (ICU) admissions.</p><p><strong>Methods: </strong>A novel ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on invasive mechanical ventilation and/or vasopressors was created in 2013 at Stanford Hospital. Inclusion criteria are: agreement by the surrogate decision maker to no titration of life support and initiation of comfort care within 18 h of EDOU admission. Exclusion criteria are: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to the bedside. We also analyzed patient characteristics, clinical operation data, and safety data.</p><p><strong>Results: </strong>23 patients were identified in the study cohort. The average patient age was 76, and 48 % were female. Three ED diagnoses for the cohort were intracranial hemorrhage (57 %), cardiac arrest (26 %), and respiratory failure (17 %). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100 % of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18 h of EDOU admission (median time from EDOU arrival to extubation 1.1 h (IQR 0.2-3.2)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU.</p><p><strong>Conclusion: </strong>The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It can be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"93-97"},"PeriodicalIF":2.7,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030286","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Accuracy of point-of-care ultrasound in diagnosing retained products of conception.","authors":"Zachary Boivin, Douglas Barber, Brock Chimileski, Thomas Fetherston, Jia Jian Li, Rachel Liu, Christopher L Moore","doi":"10.1016/j.ajem.2025.01.032","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.032","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Retained products of conception (RPOC) refers to residual intrauterine tissue in female patients after a recent birth, pregnancy termination, or miscarriage. Ultrasound is the primary diagnostic modality for RPOC, but the accuracy of point-of-care ultrasound (POCUS) has not been evaluated for this diagnosis. Our aim was to determine the test characteristics of POCUS in detecting RPOC, and to evaluate the management of RPOC in the Emergency Department.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This was a retrospective cohort study of all patients presenting to an Emergency Department with over 110,000 annual visits between January 1, 2017, and December 31, 2023, who had an Emergency Department performed pelvic POCUS. All Emergency Department patients ≥18 years old who had a pelvic POCUS performed during the study period and had no identifiable intrauterine pregnancy were included. Patients were excluded if their sex was male, age was greater than 55, if there was inadequate chart data, or if there were inadequate or no POCUS images saved. Chart review was conducted by three nonblinded investigators, and POCUS review was conducted by two ultrasound fellows, blinded to the chart review. RPOC on POCUS was defined as heterogenous or hyperechoic products within the endometrium measuring greater than 10 mm. The gold standard for the diagnosis of RPOC on chart review was radiology ultrasound or obstetrics and gynecology (OBGYN) diagnosis for patients who did not receive a radiology ultrasound.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;There were 703 patients included in the study while 58 met exclusion criteria, leaving 645 patients for review. Radiology ultrasound was performed in 512 patients (79.4 %), and identified 42 cases of RPOC. In the 133 patients who did not receive a radiology ultrasound, 20 were confirmed to have RPOC based on OBGYN diagnosis, for a total of 62 patients with RPOC (a 9.6 % prevalence). There were 70 total POCUS examinations identified as RPOC, with 17 indeterminant examinations. In the 265 patients with a history concerning for RPOC based on chart review, the sensitivity and specificity for RPOC on POCUS were 79.0 % (95 % CI; 66.1 %-88.6 %) and 93.8 % (95 % CI; 90.0 %-96.6 %) respectively when compared to the gold standard diagnosis. If all eight indeterminant POCUS examinations from this group were considered positive, the sensitivity and specificity were 80.7 % (95 % CI; 68.1 %-90.0 %) and 90.4 % (95 % CI; 85.5 %-94.0 %) and 80.7 % (95 % CI; 68.1 %-90.0 %). Of the 62 total patients with RPOC based on chart review, 21 (33.9 %) were admitted, 26 (41.9 %) had a surgical procedure, 26 (41.9 %) were managed medically, and 10 (16.1 %) were expectantly managed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;POCUS demonstrated high specificity and low sensitivity for diagnosing RPOC in patients with a history concerning for RPOC. POCUS can be used to diagnose RPOC, but caution should be exercised when making the diagnosis in early","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"65-70"},"PeriodicalIF":2.7,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Handheld ultrasound vs standard machines: Is success or ease of use the key determinant in IV placement?","authors":"Emre Kudu, Ali Batur","doi":"10.1016/j.ajem.2025.01.025","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.025","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-01-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nurse vs physician decision-making in the ED for short acting β2-agonist administration in pediatric asthma.","authors":"Nitai A Levy, Shereen Hawash, Riad Shiekh, Idit Pasternak","doi":"10.1016/j.ajem.2025.01.016","DOIUrl":"https://doi.org/10.1016/j.ajem.2025.01.016","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate triage nurses' clinical judgment in determining short acting β2-agonist bronchodilator therapy need for children with shortness of breath in the pediatric emergency department, without prior physician assessment.</p><p><strong>Methods: </strong>This prospective study compared decision-making between triage nurses and physicians regarding bronchodilator inhalation therapy necessity. Trained nurses assessed children aged 2-18 with shortness of breath, including history-taking, vital signs, and lung auscultation. Nurses made short acting β2-agonist therapy decisions based on predefined criteria. Pediatric specialists independently evaluated patients and recorded their decision.</p><p><strong>Results: </strong>Analysis of 62 assessments from 31 patients showed no statistically significant difference between nurses and doctors in administering inhaled bronchodilators (nurses: 87.1 %, doctors: 83.9 %). Clinical sign detection was similar, except for tachypnea (nurses: 48.4 %, doctors: 71 %, P = 0.07). McNemar's test and Cohen's kappa coefficient demonstrated strong nurse-doctor correlation per patient (accuracy: 83.9 %, P = 0.1; kappa: 0.351).</p><p><strong>Conclusions: </strong>Nurses excelled in recognizing certain clinical signs but showed lower compatibility in others. For severe cases, nurses consistently identified patients needing additional treatments.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"90 ","pages":"78-80"},"PeriodicalIF":2.7,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143016992","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}