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PubMed2005

[Invasive techniques in emergency medicine. III. Intraosseous punction--an alternative vascular access in paediatric emergencies].

There can be few more daunting challenges for the emergency physician than an infant or small child in shock or cardiac arrest. At the best of times, the combination of small veins and abundant subcutaneous tissue makes vascular access difficult or impossible, even in experienced hands. For these situations, the intraosseous vascular access is an easy, rapid and safe alternative. The intraosseous route is recommended for children < or =6 years of age, where conventional vascular access cannot be timely established. The preferred sites are the medial aspect of the proximal end of the tibia, just below the tibial tuberosity. Access should be obtained with a commercially available intraosseous needle. All emergency drugs and infusion fluids for intravenous usage can safely be infused via the intraosseous route (except hypertonic solutions) and it is not necessary to adjust drug dosage compared to the intravenous route. To avoid complications caused by the intraosseous needle, such as osteomyelitis, it should be replaced within 2 h by a conventional vascular access.

Anesthesia, General↗

PubMed2002

Pediatric emergencies: thoracic emergencies.

Emergencies always require rapid diagnosis and an urgent or semi-urgent medical, interventional, or surgical action. In most cases radiology plays an essential role in making an accurate diagnosis. Reviewing the causes of acute respiratory pathology in the different pediatric age groups, we thought it would be interesting to divide the pathologies into two main parts: one part concerning pathologies involving the air flow and the other part concerning pathology affecting the pulmonary parenchyma. We acknowledge, however, that both conditions can occur concomitantly. The esophagus is another anatomic structure in the thorax that can be responsible for acute pathology in children. Acute pathology predominantly involving the air flow can be intrinsic and/or extrinsic, affecting the upper airways, trachea, main and segmental bronchi, and the small airways. Acute lung pathology can be congenital, infectious, or less frequently, tumoral or traumatic in children. Pleural pathology and cardiogenic emergencies are discussed also. Acute esophageal pathology is discussed briefly.

Child↗

PubMed2002

Emerging and re-emerging infectious diseases.

In human history, numerous infectious diseases have emerged and re-emerged. Aside from many others, the so-called 'exotic' agents in particular are a threat to our public health systems due to limited experience in case management and lack of appropriate resources. Many of these agents are zoonotic in origin and transmitted from animals to man either directly or via vectors. The reservoirs are often infected subclinically or asymptomatically and the distribution of the diseases basically reflects the range and the population dynamics of their reservoir hosts. As examples, emergence/re-emergence is discussed here for diseases caused by filoviruses, hantaviruses, paramyxoviruses, flaviviruses and Yersinia pestis. In addition, bioterrorism is addressed as one factor which has now to be considered in infectious disease emergence/re-emergence. Preparedness for known and unknown infectious diseases will be a top priority for our public health systems in the beginning of the millennium.

Animals↗

PubMed2005

Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia.

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of 'pneumonia' or 'possible pneumonia' from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as 'pneumonia', 'possible pneumonia', 'non-pneumonia' and 'normal', and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of 'pneumonia', 304 (45.3%) RR's reported 'pneumonia' and 82 (12.2%), 'possible pneumonia'. Of 815 EP diagnoses of 'pneumonia' or 'possible pneumonia', 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.

Clinical Competence↗

PubMed2006

Triage of geriatric patients in the emergency department: validity and survival with the Emergency Severity Index.

STUDY OBJECTIVE: We evaluate the validity of the Emergency Severity Index (version 3) (ESI) triage algorithm in a geriatric emergency department (ED) population and determine the association between ESI categorization and survival. METHODS: Validity was assessed using a retrospective analysis of hospitalization, ED length of stay, and observed resource use compared with resource utilization estimated at triage by the ESI. Survival analysis was conducted for the same cohort. The study was exempted by the hospital institutional review board, and the requirement for informed consent was waived. RESULTS: During the investigation, 1,087 patients older than 65 years were registered in the ED. Six patients were identified as direct admissions, and 152 were found to be repeat visitors, leaving 929 subject visits for analysis. In this cohort, hospitalization was associated with ESI triage assignment (Kendall's tau-b=-0.476; 95% confidence interval [CI] -0.524 to -0.425). The area under the receiver operating characteristic curve for the predictive ability of the ESI for hospitalization was 0.77 (95% CI 0.748 to 0.806). Length of stay was associated with ESI assignment (Kruskal-Wallis test, P=.000). The relationship between triage categorization and resource utilization was significant (Spearman's correlation=-0.683; 95% CI -0.716 to -0.647). ESI categorization was associated with vital status at 1 year (Kaplan-Meier chi2 67.85; df=4; P=.0000). CONCLUSION: When used to triage patients older than 65 years, the ESI algorithm demonstrates validity. Hospitalization, length of stay, resource utilization, and survival were all associated with ESI categorization in this cohort.

Aged↗

PubMed2006

B-type natriuretic peptide (BNP) levels and ethnic disparities in perceived severity of heart failure: results from the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) multicenter study of BNP levels and emergency department decision making in patients presenting with shortness of breath.

BACKGROUND: Previous studies have shown that in patients presenting to the emergency department (ED) with heart failure, there is a disconnect between the perceived severity of congestive heart failure (CHF) by physicians and the severity as determined by B-type natriuretic peptide (BNP) levels. Whether ethnicity plays a role in this discrepancy is unknown. METHODS AND RESULTS: The Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT) was a 10-center trial of 464 patients seen in the ED with acute dyspnea and BNP level higher than 100 pg/mL on arrival. Physicians were blinded to BNP levels. Patients were followed for 90 days after discharge. A total of 151 patients identified themselves as white (32.5%) and 294 as black (63.4%). Of these, 90% were hospitalized. African Americans were more likely to be perceived as New York Heart Association class I or II than whites (P = .01). Blacks who were discharged from the ED had higher median BNP levels than whites who were discharged (1293 vs. 533, P = .004). The median BNP of blacks who were discharged was actually higher than the median BNP of blacks who were admitted (1293 vs. 769, P = .04); the same did not hold true for whites. BNP was predictive of 90-day outcome in both blacks and whites; however, perceived severity of CHF, race, and ED disposition did not contribute to the prediction of events. CONCLUSION: In patients presenting to the ED with heart failure, the disconnect between perceived severity of CHF and severity as determined by BNP levels is most pronounced in African Americans.

Black or African American↗

PubMed2005

Emergency medical service aspects of emergency cardiac care.

Prehospital intervention has the potential for significantly affecting the outcome of cardiovascular emergencies. The authors examine multiple issues in prehospital care that can streamline and improve cardiac care. Improving access to prehospital care and increasing the use of the emergency medical services (EMS) system can speed interventions to the patients. The use of ECG in the out-of-hospital setting can reduce time to definitive treatment. Issues, such as the use of public access defibrillation and interfacility transports are also discussed.

Coronary Care Units↗

PubMed2006

Reasons for the increase in emerging and re-emerging viral infectious diseases.

In the past two decades, humans have faced many new viral infectious agents in emerging and re-emerging infectious diseases (EIDs). Many factors contribute to the appearance of EIDs. These factors are complex but can be classified into three different categories: virus factors, human factors, and ecological factors. The factors contributing to the cause of such viral infectious diseases will be systematically reviewed in this article.

Animals↗

PubMed2001

Predictors of short-term deterioration and compliance in psychiatric emergency patients: a prospective study of 457 patients referred to the emergency room of a general hospital.

The aim of this study was to identify predictors of (1) short-term outcome and (2) short-term compliance with treatment (for non-hospitalized patients) in psychiatric emergency patients. Subjects comprised 457 patients referred to the emergency ward of a French general hospital and requiring examination by a psychiatrist. Clinical and therapeutic assessments were carried out at baseline, using DSM-IV diagnoses and overall psychopathological scoring scales [Brief Psychiatric Rating Scale (BPRS) and Symptom Checklist-90 Revised]. Clinical outcome and compliance were assessed 3 weeks after entry. For each of the two issues assessed, stepwise logistic regression analysis was performed following univariate comparisons. The three best predictors of deterioration at 3 weeks were lack of compliance to treatment, presence of a previous psychiatric history, and a low BPRS hebephrenic factor score. The best predictors of compliance in non-hospitalized patients were a previous psychiatric history, marital status, a low BPRS hostility factor score, and older age. The main predictor of deterioration was non-compliance. Thus, we emphasize the importance of improving compliance, especially among young patients with no previous psychiatric history.

Adult↗

PubMed1996

Rapid-sequence intubation of the pediatric patient. Pediatric Emergency Medicine Committee of the American College of Emergency Physicians.

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Age Factors↗

PubMedDate not supplied

Residency-trained emergency physicians: their demographics, practice evolution, and attrition from emergency medicine.

Concern exists about the ability of Emergency Physicians (EPs) to maintain a career in Emergency Medicine (EM) over a professional lifetime. The objectives of this study were to assess the practice characteristics of residency trained EPs, to document how the EP's responsibilities evolve throughout a career, and to assess career longevity. A retrospective cohort study using a mailed questionnaire was used to document practice characteristics, evolution of responsibility, and career longevity from all physicians who graduated from allopathic EM residencies between 1978-1988 (inclusive). Non-responders were compared to responders to assess the extent of selection bias. The response rate was 58.1% (1635/2812). There were no differences between responders and non-responders on any of five demographic variables. Responders who were more likely to remain in EM included those who had higher reimbursement, were board certified in EM, or did not train in another specialty or do a fellowship outside of EM. Throughout the 15-year careers studied, EPs noted a significant shift in the time spent doing clinical work (decreased) and the time doing administrative work (increase). The attrition from EM practice for this cohort was < 1% per year.

Adult↗

PubMed1997

Developing the emergency nurse practitioner role in accident and emergency: a bottom-up approach.

This paper discusses how the Accident and Emergency Nursing Development Unit (NDU) in Dewsbury, UK, has developed the role of the emergency nurse practitioner. Each individual member of the Nursing Development Unit (NDU) contributed to this change in practice. Maintaining these contributions to practice development was as important as the practice itself. The NDU exists to support and facilitate a bottom-up approach. This paper will discuss the whole development process and will not therefore include all the details and results from what was a 2-year process.

Curriculum↗

PubMedDate not supplied

Ethical challenges in emergency medical services. A special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians.

Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. These conflicts surround issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. Education and information regarding ethical issues are important for the providers of prehospital medical care as well as the medical director. Policies and protocols must continue to be developed to address requests to limit resuscitation, such as refusal of care and patient confidentiality. Policies should be developed in conjunction with experienced legal advice. Current training does not equip even the most advanced prehospital care provider to deal easily with every potential situation. Many learn by experience, some are guided by clear policy. Ideally, medical control personnel will be educated, interested, and available to address dilemmas which arise. Where possible, policies and procedures should be developed to address ethical issues which are likely to be faced by EMS personnel.

Confidentiality↗

PubMed2004

The challenge of emerging and re-emerging infectious diseases.

Infectious diseases have for centuries ranked with wars and famine as major challenges to human progress and survival. They remain among the leading causes of death and disability worldwide. Against a constant background of established infections, epidemics of new and old infectious diseases periodically emerge, greatly magnifying the global burden of infections. Studies of these emerging infections reveal the evolutionary properties of pathogenic microorganisms and the dynamic relationships between microorganisms, their hosts and the environment.

Animals↗

PubMed1999

SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK: an international randomized trial of emergency PTCA/CABG-trial design. The SHOCK Trial Study Group.

BACKGROUND: Cardiogenic shock (CS) is the leading cause of death in patients hospitalized with acute myocardial infarction (MI). Nonrandomized studies suggest reduced mortality rate with revascularization. TRIAL DESIGN: The SHOCK trial is a multicenter, randomized, and unblinded study with a Registry for trial-eligible and ineligible nonrandomized patients. The trial is testing the hypothesis that a direct invasive strategy of emergency revascularization for patients with cardiogenic shock complicating acute MI will reduce 30-day all-cause mortality rate by 20 absolute percentage points compared with initial medical stabilization. Eligibility criteria include development of CS within 36 hours of an acute transmural MI as evidenced by ST elevation or new left bundle branch block MI; clinical criteria for CS with hemodynamic confirmation; absence of a mechanical, iatrogenic, or other cause of shock; and enrollment within 12 hours of CS diagnosis. Patients randomly assigned to emergency revascularization immediately undergo coronary angiography, with percutaneous transluminal coronary angioplasty or coronary artery bypass grafting depending on the coronary anatomy. Patients assigned to initial medical stabilization may undergo revascularization >/=54 hours after randomization. END POINTS: The primary end point is all-cause 30-day mortality after randomization. Secondary end points include death at trial termination, changes in left ventricular dimensions and function measured by echocardiography at randomization and 2 weeks later, and changes in quality of life and physical functioning from 2 weeks after discharge to 6 months after MI.

Angioplasty, Balloon, Coronary↗

PubMedDate not supplied

Time saved with the use of emergency warning lights and siren while responding to requests for emergency medical aid in a rural environment.

OBJECTIVE: To determine whether the use of warning lights and siren saves a significant amount of time for ambulances responding to requests for emergency medical aid in a rural emergency medical services (EMS) setting. METHODS: A prospective design was used to determine run times for ambulances responding to calls with lights and siren (code 3) and for a similarly equipped "chase" ambulance traveling to the same destination via the same route without lights and siren, while obeying all traffic laws (code 2) within a rural setting. Data were collected for run time intervals, distance traveled, visibility, road surface conditions, time of day, and day of the week. Descriptive statistics, a paired Student's t-test, and analysis of variance were used to test for significant differences between code 2 and code 3 operations, as well as the other variables listed above. RESULTS: Sixty-seven runs were timed during a 21-month period. The average code 3 response interval was 8.51 minutes. The average code 2 response interval was 12.14 minutes. The 3.63 minutes saved on average represents significant time savings of 30.9% (p < 0.01). Shorter runs had higher time savings per mile than the longer runs. Run distance was the only variable that was statistically significant in affecting time saved during a code 3 response. CONCLUSION: Code 3 operation by EMS personnel in a rural EMS setting saved significant time over code 2 operation when traveling to a call.

Ambulances↗

PubMedDate not supplied

Uncompensated care provided by emergency physicians in Florida emergency departments.

Uncompensated emergency department (ED) visits can negatively affect patients, clinicians, and hospitals, particularly as overcrowding occurs. Florida provides a unique market to analyze uncompensated ED care due to the high percent of for-profit hospitals, which typically provide significantly less uncompensated care, coupled with the older population that is more likely to be insured through Medicare. A survey of 188 Florida hospital emergency physician groups was conducted to estimate the level of uncompensated care provided by each ED physician group in 1998. The response rate was 44 percent (eighty-three ED physician groups). All ED physician groups provided substantial uncompensated care regardless of hospital ownership type. Uncompensated care averaged 46.8 percent and ranged from 25.8 to 79.4 percent. A model was developed to predict the amount of uncompensated care using ED volume and payer mix. A rise in the percent of self-pay patients causes a disproportionate increase in uncompensated care, such that EDs with high levels of self-pay visits have markedly higher uncompensated care rates. The results suggest the need for a uniform reporting method of ED physician uncompensated care cost.

Data Collection↗

PubMed1994

Characteristics, workload, and job satisfaction of attending physicians from pediatric emergency medicine fellowship programs. Pediatric Emergency Medicine Collaborative Research Committee.

The purpose of this study was to determine the characteristics of academic Pediatric Emergency Medicine (PEM) faculty, the workload of these physicians, and the perceived effect this workload has had or will have on job satisfaction. A self-administered, seven-page, closed-end survey was used. participants were PEM departments with PEM Fellowship Training Programs. Surveys were completed by 37 PEM departments (84%). The average number of faculty per department was 7.33. Ninety-three percent of the faculty were board certified in Pediatrics, Emergency Medicine, or both. Only 15% of the faculty had an academic rank of associate or full professor. Fifty-four percent of the faculty had less than five years' experience. Average patient census per department was 43,400 per year. Physicians without administrative titles averaged 30 clinician hours per week. Attending physicians covered 85 to 100% of the overnight shifts in 17 programs (52%). Clinical workload was believed to be excessive in 17 programs (46%), with total number of hours given as the most common reason for this excess. In nine of these 17 programs, excess clinical workload had resulted in physician "burnout." Physicians from only eight programs (22%) believed they could practice PEM after 50 years of age. Shift work and overnight shifts were given as the most common reason. Stressed physician groups were significantly associated with programs whose attending physicians covered > or = 85% of the night shifts (P < 0.04) and reported excessive clinical workload (P < 0.002). Job satisfaction perceived by PEM faculty appears to be dependent on addressing the clinical workload and the adverse effects of overnight and shift work.

Burnout, Professional↗