Annals of Emergency Medicine RSS feed: Articles in Press. Scope and Stature of the Journal Annals of Emergency Medicine , the official journal of the American College of Emergency Physicians, is an international, peer-reviewed journal dedicated to improving the quality of care by publishing the highest quality science for emergency medicine and related medical specialties. Annals publishes original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine. In addition to general emergency medicine topics, Annals regularly publishes articles on out-of-hospital emergency medical services, pediatric emergency medicine, injury and disease prevention, health policy and ethics, disaster management, toxicology, and related topics. The journal welcomes submissions from international contributors and researchers of all specialties. Although Annals of Emergency Medicine is the official journal of the American College of Emergency Physicians (ACEP) the journal maintains editorial independence from ACEP. Its content is selected by the editorial board and does not necessarily reflect the policies and beliefs of ACEP. Annals continues to be the largest circulation peer review journal in emergency medicine (over 28,000 subscribers, several times its nearest competitor). It is also one of the most accessible to non-subscribing readers, since 6,400 institutions include Annals in their online licenses for ScienceDirect (the world's largest electronic collection of science, technology and medicine full text and bibliographic information). ScienceDirect was utilized for access to Annals articles approximately 658,000 times last year, a 19% increase from the prior year. Annals is also available on the Web (with full text of all articles dating back to its inception), where it received more than 392,000 visitors. Annals is the emergency medicine journal most frequently cited by authors and has the highest impact factor over the years of all 19 journals in the emergency medicine category of the SCI (Science Citation Index). The impact factor (the average number of citations per published article) is the commonest measure of journal influence; the 2010 impact factor for Annals was 4.14, placing it in the top 12% of all 8,005 science and medical journals tracked by the SCI. Not only is Annals most frequently cited, but it is cited more promptly and longer than any other emergency medicine journal (9.5 years, 83% longer than its nearest competitor). In the past 5 years, more than1,200 different journals in the ISI science journal database cited an article in Annals , and in a typical year, Annals articles are cited by more than 400 different scientific journals, most of them from a broad range of specialties outside of emergency medicine. Annals ' articles generate considerable interest in the lay media. From October 2009 through September 2010, there were 5,089 hits in various media outlets, including print, radio and blogs. Major outlets included Wall St. Journal , ABC News, Boston Globe, Business Week, Los Angeles Times, MSNBC, USA Today, New York Times, Modern Healthcare, Washington Post, the AM News, EM News, JEMS, and Reuters Health, as well as many trade publications. Annals is an international journal; 54% of the full text articles accessed via ScienceDirect were downloaded by readers in 93 countries outside the U.S. Our contributors are also international in scope; in 2010 submissions came to us from 46 different countries, with 41% of submissions originating outside the United States, and 25% originating outside North America and Western Europe. The largest volume other than the U.S. was submitted from Taiwan, Canada, Turkey, France, United Kingdom, China, Australia, Korea, Netherlands, Italy, and Japan, in descending order. But the list also includes Brazil, Thailand, Tunisia, India, Iran, Nigeria, and Serbia. We strongly believe we have an obligation to make our journal available to international audiences regardless of their financial resources, and therefore have participated for many years in the HINARI initiative sponsored by large journal publishers ( http://www.healthinternetwork.org/src/eligibility.php ), which makes Annals available free or at greatly reduced cost in low-income countries. http://www.annemergmed.com//inpress?rss=yesElsevier Inc.en © 2011 Published by Elsevier Inc. Annals of Emergency Medicine0196-06442012-01-20 © 2011 Published by Elsevier Inc. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS0196064411018750/abstract?rss=yes Study objective: Access to automated external defibrillators and cardiopulmonary resuscitation (CPR) training are key determinants of cardiac arrest survival. State police officers represent an important class of cardiac arrest first responders responsible for the large network of highways in the United States. We seek to determine accessibility of automated external defibrillators and CPR training among state police agencies. Methods: Contact was attempted with all 50 state police agencies by telephone and electronic mail. Officers at each agency were guided to complete a 15-question Internet-based survey. Descriptive statistics of the responses were performed. Results: Attempts were made to contact all 50 states, and 46 surveys were completed (92% response rate). Most surveys were filled out by police leadership or individuals responsible for medical programs. The median agency size was 725 (interquartile range 482 to 1,485) state police officers, with 695 (interquartile range 450 to 1,100) patrol vehicles (“squad cars”). Thirty-three percent of responding agencies (15/46) reported equipping police vehicles with automated external defibrillators. Of these, 53% (8/15) equipped less than half of their fleet with the devices. Regarding emergency medical training, 78% (35/45) of state police agencies reported training their officers in automated external defibrillator usage, and 98% (44/45) reported training them in CPR. Conclusion: One third of state police agencies surveyed equipped their vehicles with automated external defibrillators, and among those that did, most equipped only a minority of their fleet. Most state police agencies reported training their officers in automated external defibrillator usage and CPR. Increasing automated external defibrillator deployment among state police represents an important opportunity to improve first responder preparedness for cardiac arrest care. Automated External Defibrillator Availability and CPR Training Among State Police Agencies in the United States - Corrected ProofLior M. Hirsch, Sarah K. Wallace, Marion Leary, Kathryn D. Tucker, Lance B. Becker, Benjamin S. Abella10.1016/j.annemergmed.2011.11.034Annals of Emergency Medicine (2012)2012-01-20Annals of Emergency Medicine2012-01-20CARDIOLOGY/BRIEF RESEARCH REPORThttp://www.annemergmed.com/article/PIIS0196064411017975/abstract?rss=yes Study objective: We assess the efficacy of intravenous ketamine compared with intravenous morphine in reducing pain in adults with significant out-of-hospital traumatic pain. Methods: This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with trauma and a verbal pain score of greater than 5 after 5 mg intravenous morphine were eligible for enrollment. Patients allocated to the ketamine group received a bolus of 10 or 20 mg, followed by 10 mg every 3 minutes thereafter. Patients allocated to the morphine alone group received 5 mg intravenously every 5 minutes until pain free. Pain scores were measured at baseline and at hospital arrival. Results: A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine received a mean of 40.6 mg (SD 25 mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4 mg (SD 9.4 mg) of morphine. The mean pain score change was −5.6 (95% confidence interval [CI] −6.2 to −5.0) in the ketamine group compared with −3.2 (95% CI −3.7 to −2.7) in the morphine group. The difference in mean pain score change was −2.4 (95% CI −3.2 to −1.6) points. The intravenous morphine group had 9 of 65 (14%; 95% CI 6% to 25%) adverse effects reported (most commonly nausea [6/65; 9%]) compared with 27 of 70 (39%; 95% CI 27% to 51%) in the ketamine group (most commonly disorientation [8/70; 11%]). Conclusion: Intravenous morphine plus ketamine for out-of-hospital adult trauma patients provides analgesia superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse effects. Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial - Corrected ProofPaul A. Jennings, Peter Cameron, Stephen Bernard, Tony Walker, Damien Jolley, Mark Fitzgerald, Kevin Masci10.1016/j.annemergmed.2011.11.012Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16PAIN MANAGEMENT/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411018877/abstract?rss=yes Study objective: Patients receiving warfarin who experience minor head injury are at risk of intracranial hemorrhage, and optimal management after a single head computed tomography (CT) scan is unclear. We evaluate a protocol of 24-hour observation followed by a second head CT scan. Methods: In this prospective case series, we enrolled consecutive patients receiving warfarin and showing no intracranial lesions on a first CT scan after minor head injury treated at a Level II trauma center. We implemented a structured clinical pathway, including 24-hour observation and a CT scan performed before discharge. We then evaluated the frequency of death, admission, neurosurgery, and delayed intracranial hemorrhage. Results: We enrolled and observed 97 consecutive patients. Ten refused the second CT scan and were well during 30-day follow-up. Repeated CT scanning in the remaining 87 patients revealed a new hemorrhage lesion in 5 (6%), with 3 subsequently hospitalized and 1 receiving craniotomy. Two patients discharged after completing the study protocol with 2 negative CT scan results were admitted 2 and 8 days later with symptomatic subdural hematomas; neither received surgery. Two of the 5 patients with delayed bleeding at 24 hours had an initial international normalized ratio greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. The relative risk of delayed hemorrhage with an initial international normalized ratio greater than 3.0 was 14 (95% confidence interval 4 to 49). Conclusion: For patients receiving warfarin who experience minor head injury and have a negative initial head CT scan result, a protocol of 24-hour observation followed by a second CT scan will identify most occurrences of delayed bleeding. An initial international normalized ratio greater than 3 suggests higher risk. Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol - Corrected ProofVincenzo G. Menditto, Moira Lucci, Stefano Polonara, Giovanni Pomponio, Armando Gabrielli10.1016/j.annemergmed.2011.12.003Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16TRAUMA/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411019251/abstract?rss=yesPhysicians using the Pneumonia Severity Index are more likely to treat low-risk patients with community-acquired pneumonia as outpatients without compromising patient safety. PubMed and EMBASE were searched for peer-reviewed data from January 1981 through April 2010. Reference lists, bibliographies, and the investigators' files were also searched. There was no language restriction.Can Emergency Physicians Safely Increase the Proportion of Patients With Community-Acquired Pneumonia Who Are Treated in the Outpatient Setting? - Corrected ProofBen Hunter, Lee Wilbur10.1016/j.annemergmed.2011.12.010Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16SYSTEMATIC REVIEW SNAPSHOThttp://www.annemergmed.com/article/PIIS0196064411019299/abstract?rss=yesSEE RELATED ARTICLES, P.■■■. [Ann Emerg Med. 2012;■■:■■■.]Right-Sizing Testing for Pulmonary Embolism: Recognizing the Risks of Detecting Any Clot - Corrected ProofSteven M. Green, Donald M. Yealy10.1016/j.annemergmed.2011.12.014Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16THE PRACTICE OF EMERGENCY MEDICINE/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411019317/abstract?rss=yesAntifibrinolytic agents for traumatic hyphema may decrease the risk of secondary hemorrhage but do not appear to improve visual acuity. The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE (1950 to 2010), EMBASE (1980 to 2010), the metaRegister of Controlled Trials, ClinicalTrials.gov, bibliographies of included trials, and ISI Web of Science Social Sciences Citation Index. There were no language restrictions, and the authors attempted, though unsuccessfully, to contact investigators of included trials.Do Medical Interventions for Traumatic Hyphema Reduce the Risk of Vision Loss? - Corrected ProofJonathan Kirschner, Rawle A. Seupaul10.1016/j.annemergmed.2011.12.016Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS0196064411019792/abstract?rss=yesSEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2012;■■:■■■.]Work, Visible and Invisible - Corrected ProofRobert L. Wears10.1016/j.annemergmed.2011.12.018Annals of Emergency Medicine (2012)2012-01-16Annals of Emergency Medicine2012-01-16PATIENT SAFETY/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411018804/abstract?rss=yes We report a case of dyspnea in a 71-year-old man who underwent heterotopic heart transplantation in 2003. At presentation, electrocardiography showed ventricular fibrillation of the native heart and then a progression to both donor and recipient hearts. Synchronized electrical cardioversion restored sinus rhythm and relieved the patient from his symptoms. Worsening Dyspnea in a Man With 2 Hearts - Corrected ProofFrancesco Pratticò, Giacomo Mugnai, Michela Pavan, Giulio Trecco, Paola Perfetti, Giampaolo Rocca10.1016/j.annemergmed.2011.11.039Annals of Emergency Medicine (2012)2012-01-13Annals of Emergency Medicine2012-01-13CARDIOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411018038/abstract?rss=yes Methoxetamine, the N-ethyl derivative of ketamine, is a novel recreational drug that is not at present subject to restrictive regulations in most countries. To our knowledge, no case of methoxetamine abuse has been published to date in the scientific literature, and the only sources of information are illegal drug users' Web discussion forums. We report the first case of analytically confirmed intravenous methoxetamine abuse in a 19-year-old man. Observed signs and symptoms such as tachycardia, hypertension, confusion, agitation, stupor, ataxia, mydriasis, and nystagmus were consistent with ketamine-induced adverse effects and resolved with symptomatic treatment. According to this case report, user Web reports, and the chemical structure, methoxetamine produces ketamine-like effects. Complete recovery can be expected with supportive care. Ketamine-like Effects After Recreational Use of Methoxetamine - Corrected ProofKatharina E. Hofer, Bettina Grager, Daniel M. Müller, Christine Rauber-Lüthy, Hugo Kupferschmidt, Katharina M. Rentsch, Alessandro Ceschi10.1016/j.annemergmed.2011.11.018Annals of Emergency Medicine (2012)2012-01-12Annals of Emergency Medicine2012-01-12TOXICOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411018749/abstract?rss=yes Serotonin syndrome is associated with use of certain street drugs, including methamphetamine, cocaine, and ecstasy. We describe a case of a woman who developed clinical findings consistent with serotonin syndrome after insufflation of 3,4-methylenedioxypyrovalerone (MDPV), a synthetic amphetamine. MDPV belongs to a group of substances called phenylethylamines, which are β-ketone analogs of other drugs of abuse, such as amphetamines and 3,4-methylenedioxymethamphetamine. She also received fentanyl initially during her hospitalization, which has also been associated with serotonin syndrome. In addition to benzodiazepines and supportive care, she was treated with cyproheptadine for 8 days, with slow resolution of her symptoms. Serotonin Syndrome Associated With MDPV Use: A Case Report - Corrected ProofJosh Mugele, Kristine A. Nañagas, Laura M. Tormoehlen10.1016/j.annemergmed.2011.11.033Annals of Emergency Medicine (2012)2012-01-12Annals of Emergency Medicine2012-01-12TOXICOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411017987/abstract?rss=yes Study objective: The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). Methods: This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. Results: A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). Conclusion: Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities. A Prospective, Multicenter Study of Pharmacist Activities Resulting in Medication Error Interception in the Emergency Department - Corrected ProofAsad E. Patanwala, Arthur B. Sanders, Michael C. Thomas, Nicole M. Acquisto, Kyle A. Weant, Stephanie N. Baker, Erica M. Merritt, Brian L. Erstad10.1016/j.annemergmed.2011.11.013Annals of Emergency Medicine (2012)2012-01-09Annals of Emergency Medicine2012-01-09PATIENT SAFETY/BRIEF RESEARCH REPORThttp://www.annemergmed.com/article/PIIS0196064411018841/abstract?rss=yes Study objective: Ethylene glycol remains an important toxic cause of metabolic acidosis and acute renal failure. Traditionally, inhibition of alcohol dehydrogenase along with hemodialysis has been used for treatment. Because of reported long elimination half-life of ethylene glycol during alcohol dehydrogenase inhibition, hemodialysis has been used in patients who are otherwise doing well to clear ethylene glycol. We study ethylene glycol elimination kinetics in patients treated with fomepizole, but without hemodialysis. Methods: This was a retrospective, multicenter cohort study of patients older than 15 years who were treated at one of 3 medical centers during an 8-year period. Inclusion criteria were peak serum ethylene glycol concentration greater than 20 mg/dL, lack of renal failure on admission, treatment with fomepizole but without hemodialysis, and availability of serial serum ethylene glycol concentrations, allowing calculation of elimination half-life. The primary outcome variable was ethylene glycol elimination half-life; mortality and onset of renal failure were secondary outcome variables. Results: During the study period, 85 patients were treated for ethylene glycol toxicity, of whom 40 met inclusion criteria. The mean serum ethylene glycol elimination half-life was 14.2 hours (SD=3.7 hours; 95% confidence interval 13.1 to 15.3 hours). One patient presented with metabolic acidosis on admission and developed mild transient renal insufficiency but did not require hemodialysis. No patient died. Conclusion: The mean elimination half-life of ethylene glycol in this population was shorter than previously reported without hemodialysis, and this select group of patients did well without enhanced elimination by hemodialysis. Ethylene Glycol Elimination Kinetics and Outcomes in Patients Managed Without Hemodialysis - Corrected ProofMichael Levine, Steven C. Curry, Anne-Michelle Ruha, Anthony F. Pizon, Edward Boyer, Jarrett Burns, Dale Bikin, Richard D. Gerkin10.1016/j.annemergmed.2011.12.001Annals of Emergency Medicine (2012)2012-01-09Annals of Emergency Medicine2012-01-09TOXICOLOGY/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS019606441101701X/abstract?rss=yes Study objective: Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm. Methods: This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days. Results: We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing. Conclusion: In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain - Corrected ProofFrank Xavier Scheuermeyer, Grant Innes, Eric Grafstein, Marla Kiess, Barb Boychuk, Eugenia Yu, Daniel Kalla, Jim Christenson10.1016/j.annemergmed.2011.10.016Annals of Emergency Medicine (2012)2012-01-06Annals of Emergency Medicine2012-01-06CARDIOLOGY/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411017628/abstract?rss=yes Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes. Effective Discharge Communication in the Emergency Department - Corrected ProofMargaret E. Samuels-Kalow, Anne M. Stack, Stephen C. Porter10.1016/j.annemergmed.2011.10.023Annals of Emergency Medicine (2012)2012-01-06Annals of Emergency Medicine2012-01-06THE PRACTICE OF EMERGENCY MEDICINE/REVIEW ARTICLEhttp://www.annemergmed.com/article/PIIS0196064411018294/abstract?rss=yesThere is no clear evidence that any one pharmacologic agent or strategy is superior for the acute management of sickle cell disease–related pain in the emergency department. Evidence surrounding nonopioid adjunctive agents is conflicting, but ketorolac may provide an opioid-sparing effect, and multidose parenteral steroids may decrease inpatient hospital length of stay.What Is the Best Pharmacologic Treatment for Sickle Cell Disease Pain Crises? - Corrected ProofMari Baker, John W. Hafner10.1016/j.annemergmed.2011.11.026Annals of Emergency Medicine (2012)2012-01-06Annals of Emergency Medicine2012-01-06SYSTEMATIC REVIEW SNAPSHOThttp://www.annemergmed.com/article/PIIS0196064411018786/abstract?rss=yesContinuous nebulized β-agonist therapy reduces hospital admissions compared with intermittent β-agonist treatments in moderate to severe asthma exacerbations. The investigators searched the Cochrane Airways Group Specialized Register of Trials. Authors, personal contacts, and advisors to pharmaceutical companies were contacted, and reference lists of studies used were reviewed to identify any further studies.Is Continuous Nebulized β-Agonist Therapy More Effective Than Intermittent β-Agonist Therapy at Reducing Hospital Admissions in Acute Asthma? - Corrected ProofAngela K. Gregory, Christian H. Jacobus10.1016/j.annemergmed.2011.11.037Annals of Emergency Medicine (2012)2012-01-06Annals of Emergency Medicine2012-01-06SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS0196064411017616/abstract?rss=yes Study objective: To perform a systematic review and meta-analysis to define the diagnostic performance of pulmonary embolism rule-out criteria (PERC) in deferring the need for D-dimer testing to rule out pulmonary embolism in the emergency department (ED). Methods: We searched EMBASE, MEDLINE, Scopus, Web of Knowledge, and all the evidence-based medicine reviews that included the Cochrane Database of Systematic Reviews through August 14, 2011, and hand searched references in potentially eligible articles and conference proceedings of major emergency medicine organizations for the previous 2 years. We selected studies that reported diagnostic performance of PERC, reported original research, and were conducted in the ED, with no language restrictions. Two investigators independently identified eligible studies and extracted data. We used contingency tables to calculate sensitivity, specificity, and likelihood ratios. Results: We found 12 qualifying cohorts (studying 13,885 patients with 1,391 pulmonary embolism diagnoses), 10 prospective and 2 retrospective, from 6 countries. Pooled sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios for 10 included studies were 0.97 (95% confidence interval [CI] 0.96 to 0.98), 0.23 (95% CI 0.22 to 0.24), 1.24 (95% CI 1.18 to 1.30), and 0.17 (95% CI 0.13 to 0.23), respectively. Significant heterogeneity was observed in specificity (I2=97.2%) and positive likelihood ratio (I2=84.2%). Conclusion: The existing literature suggests consistently high sensitivity and low but acceptable specificity of the PERC to rule out pulmonary embolism in patients with low pretest probability. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis - Corrected ProofBalwinder Singh, Ajay K. Parsaik, Dipti Agarwal, Alok Surana, Soniya S. Mascarenhas, Subhash Chandra10.1016/j.annemergmed.2011.10.022Annals of Emergency Medicine (2011)2011-12-19Annals of Emergency Medicine2011-12-19THE PRACTICE OF EMERGENCY MEDICINE/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411017574/abstract?rss=yesThe use of tranexamic acid may reduce the risk of death in bleeding trauma patients. In July 2010, the authors searched the Cochrane Injuries Group's specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Science Citation Index, National Research Register, Zetoc, SGILE, Global Health, LILACS, and Current Controlled Trials.Does the Administration of Antifibrinolytic Drugs in Acute Trauma Reduce Mortality? - Corrected ProofJoshua Bozek, Steven Zimmerman10.1016/j.annemergmed.2011.10.019Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS019606441101763X/abstract?rss=yesSEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2011;■■:■■■.]Singularities, Odds Ratios, and Significance: California Emergency Department Closures and Los Angeles - Corrected ProofWilliam Wesley Fields10.1016/j.annemergmed.2011.10.024Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12HEALTH POLICY/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411017689/abstract?rss=yes Study objective: We determine whether, after a brief training program in procedural sedation, nurses can safely independently administer ketamine sedation in a resource-limited environment. Methods: This is an observational case series of consecutive sedations performed in an emergency department in rural Uganda at approximately 5,000 feet above sea level. The data were collected prospectively in a quality assurance database. As part of a larger training program in emergency care at Karoli Lwanga Hospital in rural Uganda, nurses with no sedation experience were trained in procedural sedation with ketamine. All sedations were monitored by a nonphysician research assistant, who recorded ketamine dosing, duration of each procedure, adverse events, and nurse interventions for each adverse event. In accordance with standard definitions in the emergency medicine sedation literature, adverse events were defined a priori and classified as major (death, need for bag-valve-mask ventilation, or unanticipated admission to the hospital) or minor (hypoxia, vomiting, emergence reactions, hypersalivation). The primary statistical analysis was descriptive, with reporting of adverse event rates with 95% confidence intervals (CIs), using the nurse as the unit of analysis. Results: There were a total of 191 administrations by 6 nurses during the study period (December 2009 through March 2010). Overall, there was an 18% adverse event rate (95% CI 7% to 30%), which is similar to the rate reported in resource-rich countries. These events included hypoxia (22 cases; 12%), vomiting (9 cases; 5%), and emergence reaction (7 cases; 4%). All adverse events met our a priori defined criteria for minor events, with a 0% incidence of major events (1-sided 97.5% CI with the nurse as unit of analysis 0% to 46%). The procedural success rate was 99%. Sedation was practitioner rated as “excellent” in 91% of cases (95% CI 86% to 94%) and “good” in 9% (95% CI 6% to 14%). Patients reported they would want ketamine for a future procedure in 98% of cases (95% CI 95% to 100%). Conclusion: In resource-limited settings, nurse-administered ketamine sedation appears to be safe and effective. A brief procedural sedation training program, coupled with a comprehensive training program in emergency care, can increase access to appropriate and safe sedation for patients in resource-limited settings. Nurse-Administered Ketamine Sedation in an Emergency Department in Rural Uganda - Corrected ProofMark Bisanzo, Kelly Nichols, Heather Hammerstedt, Bradley Dreifuss, Sara W. Nelson, Stacey Chamberlain, Felista Kyomugisha, Amelia Noble, Annette Arthur, Stephen Thomas10.1016/j.annemergmed.2011.11.004Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12PAIN MANAGEMENT/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411017720/abstract?rss=yesIntra-articular lidocaine is as effective as fixed intravenous doses of benzodiazepine/procedural sedation for reduction of acute anterior shoulder dislocations and may be associated with fewer adverse events.Can Intra-articular Lidocaine Supplant the Need for Procedural Sedation for Reduction of Acute Anterior Shoulder Dislocation? - Corrected ProofBen Hunter, Lee Wilbur10.1016/j.annemergmed.2011.11.008Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS0196064411017768/abstract?rss=yesA normal C-reactive protein or procalcitonin result decreases the likelihood of serious bacterial infections in children but cannot be used as a rule-out test. Databases were searched up to June 2009 from MEDLINE, EMBASE, DARE, and CINHAL. In addition, snowballing strategy, in which relevant articles were identified from references of pertinent articles, was used to identify additional studies from systematic reviews, as were relevant National Institute for Health and Clinical Excellence guidelines and consultation with experts.Is There a Blood Test That Can Rule Out Serious Bacterial Infection in Children? - Corrected ProofJeffrey Hom10.1016/j.annemergmed.2011.11.009Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS019606441101777X/abstract?rss=yes Study objective: The quality measure “Rh immunoglobulin administration for Rh-negative women at risk for fetal blood exposure” was recently endorsed by the National Quality Forum. No published data have shown a related performance gap in US emergency departments (EDs). We determine performance in a US ED for appropriate Rh testing and treatment among pregnant ED patients at risk of fetal blood exposure. Methods: This was a retrospective, observational study in an urban, academic ED with 97,000 annual visits. We performed record review of all pregnant ED patients aged 14 to 50 years and presenting between June 1, 2009, and June 1, 2010, to determine whether a sensitizing event or a potential sensitizing event occurred and whether Rh testing and treatment with Rh immunoglobulin were performed when indicated. Performance rates were calculated under 2 different assumptions for patients without Rh testing ordered in the ED but who had previous data in the electronic medical record: (1) unless explicitly documented by the treating physician, previous Rh data were considered as not having been checked; and (2) when available in the electronic medical record, Rh status was always considered as having been checked. Interrater reliability was assessed for whether a trauma represented a sensitizing event. Results: Among 1,465 patients identified, 808 met inclusion criteria; 560 had a sensitizing event and 248 had a potential sensitizing event. Interrater reliability for determination of sensitizing event or potential sensitizing event in trauma was moderate (κ=0.42). Performance rates for Rh testing among patients with sensitizing events, with potential sensitizing events, and overall were 73% (95% confidence interval [CI] 69% to 76%) (408/560), 36% (95% CI 31% to 43%) (90/248), and 62% (95% CI 58% to 65%) (498/808). Appropriate treatment for patients with a sensitizing event, with a potential sensitizing event, and overall was 56% (95% CI 39% to 71%) (19/34), 0% (95% CI 0% to 49%) (0/5), and 48% (95% CI 33% to 63%) (19/39). Assuming that physicians were aware of previous Rh results yielded performance rates of 96% (95% CI 93% to 97%) (535/560), 73% (95% CI 67% to 78%) (181/248), and 89% (95% CI 86% to 91%) (716/808) and treatment performance rates of 54% (95% CI 38% to 69%) (20/37), 0% (95% CI 0% to 30%) (0/11), and 42% (95% CI 29% to 56%) (20/48). Conclusion: In this single-center study, among patients with a sensitizing event, performance was moderate for Rh testing and treatment with Rh immunoglobulin. Despite lack of consensus or uncertainties in certain measure definitions, in at least 1 US academic ED there appears to be an opportunity for further evaluation and performance improvement in this area. Performance in Appropriate Rh Testing and Treatment With Rh Immunoglobulin in the Emergency Department - Corrected ProofRichard T. Griffey, Betty C. Chen, Nicholas W. Krehbiel10.1016/j.annemergmed.2011.11.010Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12OBSTETRICS AND GYNECOLOGY/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411018002/abstract?rss=yes Clinical reports on management and rewarming complications after prolonged avalanche burial are not common. We present a case of an unreported combination of respiratory failure and unexpected spontaneous hypoglycemia during noninvasive rewarming from severe hypothermia. We collected anecdotal observations in a 42-year-old, previously healthy, male backcountry skier admitted to the ICU at a tertiary care center after 2 hours 7 minutes of complete avalanche burial, who presented with a patent airway and a core body temperature of 25.0°C (77.0°F) on extrication. There was no decrease in core body temperature during transport (from 25.0°C [77.0°F] to 24.7°C [76.5°F]). Atrial fibrillation occurred during active noninvasive external rewarming (to 37.0°C [98.6°F] during 5 hours), followed by pulmonary edema and respiratory failure (SaO2 73% and PaO2/FIO2 161 mm Hg), which resolved with endotracheal intubation and continuous positive end-respiratory pressure. Moreover, a marked spontaneous glycemic imbalance (from 22.2 to 1.4 mmol/L) was observed. Despite a possible favorable outcome, clinicians should be prepared to identify and treat severe respiratory problems and spontaneous hypoglycemia during noninvasive rewarming of severely hypothermic avalanche victims. Respiratory Failure and Spontaneous Hypoglycemia During Noninvasive Rewarming From 24.7°C (76.5°F) Core Body Temperature After Prolonged Avalanche Burial - Corrected ProofGiacomo Strapazzon, Michele Nardin, Peter Zanon, Marc Kaufmann, Meinhard Kritzinger, Hermann Brugger10.1016/j.annemergmed.2011.11.015Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12GENERAL MEDICINE/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411018014/abstract?rss=yes We report a patient with chest pain who was classified as having low risk for pulmonary embolism with clinical gestalt and accepted clinical decision rules. An inadvertently ordered D-dimer and abnormal result, however, led to the identification of a large saddle embolus. This case illustrates the fallibility of even well-validated decision aids and that an embolism missed by these tools is not necessarily low risk or indicative of a low clot burden. A Patient With a Large Pulmonary Saddle Embolus Eluding Both Clinical Gestalt and Validated Decision Rules - Corrected ProofAdam Hennessey, Devy A. Setyono, Wayne Bond Lau, Jason Matthew Fields10.1016/j.annemergmed.2011.11.016Annals of Emergency Medicine (2011)2011-12-12Annals of Emergency Medicine2011-12-12THE PRACTICE OF EMERGENCY MEDICINE/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411017008/abstract?rss=yes Study objective: Multiple studies have explored pharmacologic interventions to prevent acute mountain sickness. A systematic review of this subject published in 2000 found that both acetazolamide and dexamethasone were effective. Since 2000, a number of other agents have been reported to be beneficial. This EBEM review evaluates the most current evidence on this topic. Methods: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, SPORTDiscus, Emergency Medical Abstracts, and ClinicalTrials.gov from 2000 to July 2011. Only randomized placebo-controlled trials with an N greater than or equal to 50 and systematic reviews were reviewed. Standard criteria for assessing trial quality were independently assessed by 2 authors. Results: Seven hundred eighty-six citations were retrieved, of which 105 were reviewed in their entirety. Eleven randomized controlled trials and 1 systematic review appeared to meet inclusion criteria; however, 4 randomized controlled trials were excluded for high risk of bias. The remaining 7 randomized controlled trials investigated antioxidants, magnesium, sumatriptan, gabapentin, acetazolamide, and Ginkgo biloba. No trials studying dexamethasone met our criteria. Acetazolamide was associated with a reduction in acute mountain sickness symptoms, with a number needed to treat ranging from 8 to 3 among 3 trials and at doses ranging from 250 to 750 mg daily. Sumatriptan showed benefit in 1 trial (number needed to treat=4), as did gabapentin (number needed to treat=6). Antioxidants, magnesium, and G biloba were not efficacious. Reported adverse events included somnolence with gabapentin and paresthesias with acetazolamide. The systematic review affirmed our results but did not capture trials studying antioxidants, magnesium, sumatriptan, or gabapentin. Conclusion: Acetazolamide is effective for the prevention of acute mountain sickness but may be associated with paresthesias. Sumatriptan and gabapentin are beneficial but require further study. Pharmacologic Prophylaxis for Acute Mountain Sickness: A Systematic Shortcut Review - Corrected ProofRawle A. Seupaul, Julie L. Welch, Sarah T. Malka, Thomas W. Emmett10.1016/j.annemergmed.2011.10.015Annals of Emergency Medicine (2011)2011-12-09Annals of Emergency Medicine2011-12-09GENERAL MEDICINE/CRITICALLY APPRAISED TOPIChttp://www.annemergmed.com/article/PIIS0196064411017690/abstract?rss=yes Heat stroke is defined by central nervous system abnormalities and failure of proper maintenance of thermoregulation as a result of high core body temperature ensuing from exposure to high environmental temperatures or strenuous exercise. Common complications include acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal injury, hepatic injury, and rhabdomyolysis. Myocardial injury may also occur during heat stroke, resulting in cardiac enzyme increase and ST-segment changes on the ECG. Such findings might behave as diagnostic pitfalls by mimicking the presentation of coronary artery occlusive myocardial infarction. A previous case report described a patient with heat stroke and ST-segment elevation, in which the definite cause of the ST-segment elevation was unclear; however, acute myocardial infarction caused by coronary artery disease was ruled out according to the clinical signs, serial ECG changes, and serum level of cardiac biomarkers. Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) was suspected, but it could not be confirmed because of the lack of coronary angiography. We herein report a case of heat stroke presenting with ST-segment elevation and cardiogenic shock. Coronary angiography was performed and coronary artery occlusive myocardial infarction was ruled out because of the presence of patent coronary arteries. Left ventriculography showed midventricular and apical hypokinesis, and stress-induced cardiomyopathy was then determined to be the appropriate diagnosis. Heat stroke causes increase of serum catecholamine levels, in which oversecretion and abnormal responses to catecholamines are a possible cause of stress-induced cardiomyopathy. Catecholamines may therefore be the key in linking heat stroke and stress-induced cardiomyopathy. Stress-Induced Cardiomyopathy Caused by Heat Stroke - Corrected ProofWei-Ta Chen, Cheng-Hsin Lin, Ming-Hsiung Hsieh, Chun-Yao Huang, Jong-Shiuan Yeh10.1016/j.annemergmed.2011.11.005Annals of Emergency Medicine (2011)2011-12-09Annals of Emergency Medicine2011-12-09CARDIOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411017999/abstract?rss=yesAlbumin use during resuscitation of patients with sepsis may decrease mortality compared with other fluid solutions. Until additional studies are published, clinicians should consider albumin use an option during the initial resuscitation of patients with sepsis.Does Resuscitation With Albumin-Containing Solutions Improve Mortality in Sepsis? - Corrected ProofBrian J. Tollefson, Alan E. Jones10.1016/j.annemergmed.2011.11.014Annals of Emergency Medicine (2011)2011-12-09Annals of Emergency Medicine2011-12-09SYSTEMATIC REVIEW SNAPSHOT CLINICAL SYNOPSIShttp://www.annemergmed.com/article/PIIS0196064411017604/abstract?rss=yesStudy objective: We compare the efficacy and safety of sublingual buprenorphine versus intravenous morphine sulfate in emergency department adults with acute bone fracture.Methods: Enrolled patients received buprenorphine 0.4 mg sublingually or morphine 5 mg intravenously in this double-blind, double-dummy, randomized controlled trial. Patients graded their pain with a standard 11-point numeric rating scale before medication administration and 30 and 60 minutes after, and we recorded adverse reactions.Results: We analyzed 44 and 45 patients in the buprenorphine and morphine groups, respectively. Mean pain scores were similar at 30 minutes (5.0 versus 5.0; difference 0; 95% confidence interval −0.6 to 0.8) and at 60 minutes (2.2 versus 2.2; difference 0; 95% confidence interval −0.3 to 0.3). Adverse effects observed within 30 minutes were nausea (14% versus 12%), dizziness (14% versus 22%), and hypotension (4% versus 18%).Conclusion: For adults with acute fractures, buprenorphine 0.4 mg sublingually is as effective and safe as morphine 5 mg intravenously.Sublingual Buprenorphine in Acute Pain Management: A Double-Blind Randomized Clinical Trial - Corrected ProofMohammad Jalili, Marzieh Fathi, Maziar Moradi-Lakeh, Shahriar Zehtabchi10.1016/j.annemergmed.2011.10.021Annals of Emergency Medicine (2011)2011-11-24Annals of Emergency Medicine2011-11-24PAIN MANAGEMENT/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411016751/abstract?rss=yesCardiac dysrhythmias are a common problem in the United States. Radiofrequency ablation is being used more frequently as a treatment for these diagnoses. Although rare, serious complications such as cardiac tamponade have been reported as a result of ablation procedures. Traditionally, emergency department (ED) thoracotomy has been reserved for cases of traumatic arrest only. We report a case of a successful modified ED thoracotomy in a patient with postablation cardiac tamponade and subsequent obstructive shock who failed intravenous fluid resuscitation, pressor administration, and multiple attempts at pericardiocentesis. In this case, a modified approach was used to incise the pericardium. Although this was associated with large blood loss, we believed that using the traditional method of completely removing the pericardium would have resulted in uncontrolled hemorrhage. Instead, our method led to successful resuscitation of the patient until definitive care was available. A smaller pericardial incision than is traditionally used during ED thoracotomy deserves further consideration and research to determine whether and when it may be most useful as a temporizing treatment of cardiac tamponade when other methods have failed.Modified Emergency Department Thoracotomy for Postablation Cardiac Tamponade - Corrected ProofThomas E. Wyatt, Eric W. Haug10.1016/j.annemergmed.2011.10.010Annals of Emergency Medicine (2011)2011-11-21Annals of Emergency Medicine2011-11-21CARDIOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411016623/abstract?rss=yesStudy objective: Emergency department (ED) closures threaten community access to emergency services, but few data exist to describe factors associated with closure. We evaluate factors associated with ED closure in California and seek to determine whether hospitals serving more vulnerable populations have a higher rate of ED closure.Methods: This was a retrospective cohort study of California hospital EDs between 1998 and 2008, using hospital- and patient-level data from the California Office of Statewide Health Planning and Development (OSHPD), as well as OSHPD patient discharge data. We examined the effects of hospital and patient factors on the hospital's likelihood of ED closure by using Cox proportional hazards models.Results: In 4,411 hospital-years of observation, 29 of 401 (7.2%) EDs closed. In a model adjusted for total ED visits, hospital discharges, trauma center and teaching status, ownership, operating margin, and urbanicity, hospitals with more black patients (hazard ratio [HR] 1.41 per increase in proportion of blacks by 0.1; 95% confidence interval [CI] 1.16 to 1.72) and Medi-Cal recipients (HR 1.17 per increase in proportion insured by Medi-Cal by 0.1; 95% CI 1.02 to 1.34) had higher risk of ED closure, as did for-profit institutions (HR 1.65; 95% CI 1.13 to 2.41).Conclusion: The population served by EDs and hospitals' profit model are associated with ED closure. Whether our findings are a manifestation of poorer reimbursement in at-risk EDs is unclear.System-Level Health Disparities in California Emergency Departments: Minorities and Medicaid Patients Are at Higher Risk of Losing Their Emergency Departments - Corrected ProofRenee Y. Hsia, Tanja Srebotnjak, Hemal K. Kanzaria, Charles McCulloch, Andrew D. Auerbach10.1016/j.annemergmed.2011.09.018Annals of Emergency Medicine (2011)2011-11-17Annals of Emergency Medicine2011-11-17HEALTH POLICY/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411016994/abstract?rss=yesAdjunctive dexamethasone in bacterial meningitis may reduce mortality and hearing loss for patients in developing countries. There may be no benefit for individuals in developing nations with a high prevalence of HIV infection.Is Adjunctive Dexamethasone Beneficial in Patients With Bacterial Meningitis? - Corrected ProofDylan D. Cooper, Rawle A. Seupaul10.1016/j.annemergmed.2011.10.014Annals of Emergency Medicine (2011)2011-11-17Annals of Emergency Medicine2011-11-17SYSTEMATIC REVIEW SNAPSHOThttp://www.annemergmed.com/article/PIIS0196064411015411/abstract?rss=yesStudy objective: To address concerns about prolonged emergency department (ED) stays from crowding, England mandated that the maximum length of ED stay for 98% of patients be no greater than 4 hours. We evaluate the effect of the mandated ED care intervals in England.Methods: This was a retrospective analysis of ED patient throughput before, during, and after implementation of the target. Fifteen acute hospital trusts' ED data were purposively sampled, including all patient visits during May and June of 2003 to 2006. We compared total time in ED and time to clinician across years, segregating for admitted versus discharged patients and young versus old patients, using a random-effects regression model and adjusting for hospital clustering.Results: We analyzed 735,588 ED visits. The proportion of patients seen and treated within 4 hours improved from 83.9% to 96.3%. Adjusted total length of ED stay from 2003 to 2006 increased by 8.6 minutes for all patients and 30 minutes for admissions; time to physician improved by 1 minute for all patients. The proportion of patients leaving the ED during the last 20 minutes before 4 hours increased from 4.7% of all patients in 2003 to 8.4% in 2006. Admitted patients were more likely than discharged ones to leave the ED in the last 20 minutes, and the relative likelihood increased each year after 2003, with incidence rate ratio 1.04 (95% confidence interval [CI] 0.78 to 1.39), 1.39 (95% CI 1.05 to 1.82), and 1.55 (95% CI 1.19 to 2.20) for 2004, 2005, and 2006, respectively. An increasing proportion of elderly patients were in the last 20-minute departure interval each year compared with younger patients (in 2003 7.4% versus 4.1%; in 2006 17.3% versus 6.3%).Conclusion: The introduction of a time target reduced the proportion of patients staying greater than 4 hours. More patients departed within 20 minutes of the target 4-hour interval after the mandate, notably, the elderly.Time Patients Spend in the Emergency Department: England's 4-Hour Rule—A Case of Hitting the Target but Missing the Point? - Corrected ProofSuzanne Mason, Ellen J. Weber, Joanne Coster, Jennifer Freeman, Thomas Locker10.1016/j.annemergmed.2011.08.017Annals of Emergency Medicine (2011)2011-11-16Annals of Emergency Medicine2011-11-16HEALTH POLICY/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411015459/abstract?rss=yes Study objective: This study examines whether serum levels of glial fibrillary acidic protein breakdown products (GFAP-BDP) are elevated in patients with mild and moderate traumatic brain injury compared with controls and whether they are associated with traumatic intracranial lesions on computed tomography (CT) scan (positive CT result) and with having a neurosurgical intervention. Methods: This prospective cohort study enrolled adult patients presenting to 3 Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 9 to 15. Control groups included normal uninjured controls and trauma controls presenting to the emergency department with orthopedic injuries or a motor vehicle crash without traumatic brain injury. Blood samples were obtained in all patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP-BDP (nanograms/milliliter). Results: Of the 307 patients enrolled, 108 were patients with traumatic brain injury (97 with GCS score 13 to 15 and 11 with GCS score 9 to 12) and 199 were controls (176 normal controls and 16 motor vehicle crash controls and 7 orthopedic controls). Receiver operating characteristic curves demonstrated that early GFAP-BDP levels were able to distinguish patients with traumatic brain injury from uninjured controls with an area under the curve of 0.90 (95% confidence interval [CI] 0.86 to 0.94) and differentiated traumatic brain injury with a GCS score of 15 with an area under the curve of 0.88 (95% CI 0.82 to 0.93). Thirty-two patients with traumatic brain injury (30%) had lesions on CT. The area under these curves for discriminating patients with CT lesions versus those without CT lesions was 0.79 (95% CI 0.69 to 0.89). Moreover, the receiver operating characteristic curve for distinguishing neurosurgical intervention from no neurosurgical intervention yielded an area under the curve of 0.87 (95% CI 0.77 to 0.96). Conclusion: GFAP-BDP is detectable in serum within an hour of injury and is associated with measures of injury severity, including the GCS score, CT lesions, and neurosurgical intervention. Further study is required to validate these findings before clinical application. Elevated Levels of Serum Glial Fibrillary Acidic Protein Breakdown Products in Mild and Moderate Traumatic Brain Injury Are Associated With Intracranial Lesions and Neurosurgical Intervention - Corrected ProofLinda Papa, Lawrence M. Lewis, Jay L. Falk, Zhiqun Zhang, Salvatore Silvestri, Philip Giordano, Gretchen M. Brophy, Jason A. Demery, Neha K. Dixit, Ian Ferguson, Ming Cheng Liu, Jixiang Mo, Linnet Akinyi, Kara Schmid, Stefania Mondello, Claudia S. Robertson, Frank C. Tortella, Ronald L. Hayes, Kevin K.W. Wang10.1016/j.annemergmed.2011.08.021Annals of Emergency Medicine (2011)2011-11-10Annals of Emergency Medicine2011-11-10TRAUMA/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411016635/abstract?rss=yesSEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2011;■■:■■■.]Rethinking Out-of-Hospital Intravenous Access - Corrected ProofSamuel J. Stratton10.1016/j.annemergmed.2011.09.019Annals of Emergency Medicine (2011)2011-11-04Annals of Emergency Medicine2011-11-04EMERGENCY MEDICAL SERVICES/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411016672/abstract?rss=yesPatients requiring emergency airway management are at great risk of hypoxemic hypoxia because of primary lung pathology, high metabolic demands, anemia, insufficient respiratory drive, and inability to protect their airway against aspiration. Tracheal intubation is often required before the complete information needed to assess the risk of periprocedural hypoxia is acquired, such as an arterial blood gas level, hemoglobin value, or even a chest radiograph. This article reviews preoxygenation and peri-intubation oxygenation techniques to minimize the risk of critical hypoxia and introduces a risk-stratification approach to emergency tracheal intubation. Techniques reviewed include positioning, preoxygenation and denitrogenation, positive end expiratory pressure devices, and passive apneic oxygenation.Preoxygenation and Prevention of Desaturation During Emergency Airway Management - Corrected ProofScott D. Weingart, Richard M. Levitan10.1016/j.annemergmed.2011.10.002Annals of Emergency Medicine (2011)2011-11-04Annals of Emergency Medicine2011-11-04AIRWAY/REVIEW ARTICLEhttp://www.annemergmed.com/article/PIIS0196064411016052/abstract?rss=yesStudy objective: The purpose of this study is to determine whether older adults presenting to the emergency department (ED) with pain are less likely to receive pain medication than younger adults.Methods: Pain-related visits to US EDs were identified with reason-for-visit codes from 7 years (2003 to 2009) of the National Hospital Ambulatory Medical Care Survey. The primary outcome was the administration of an analgesic. The percentage of patients receiving analgesics in 4 age groups was adjusted for measured covariates, including pain severity.Results: Pain-related visits accounted for 88,031 (46.9%) ED visits by patients aged 18 years or older during the 7-year period. There were 7,585 pain-related ED visits by patients aged 75 years or older, representing an estimated 3.65 million US ED visits annually. In comparing survey-weighted unadjusted estimates, pain-related visits by patients aged 75 years or older were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). Absolute differences in rates of analgesic and opioid administration persisted after adjustment for sex, race/ethnicity, pain severity, and other factors and multiple imputation of missing pain severity data, with visits by patients aged 75 years and older being 19.6% (95% confidence interval 17.8% to 21.4%) less likely than visits by patients aged 35 to 54 years to receive an analgesic and 14.6% (95% confidence interval 12.8% to 16.4%) less likely to receive an opioid.Conclusion: Patients aged 75 years and older with pain-related ED visits are less likely to receive pain medication than patients aged 35 to 54 years.Older US Emergency Department Patients Are Less Likely to Receive Pain Medication Than Younger Patients: Results From a National Survey - Corrected ProofTimothy F. Platts-Mills, Denise A. Esserman, D. Levin Brown, Andrey V. Bortsov, Philip D. Sloane, Samuel A. McLean10.1016/j.annemergmed.2011.09.014Annals of Emergency Medicine (2011)2011-10-28Annals of Emergency Medicine2011-10-28PAIN MANAGEMENT/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411006147/abstract?rss=yesTopical nonsteroidal anti-inflammatory drugs effectively reduce pain associated with musculoskeletal conditions compared with placebo, with fewer adverse events compared with oral nonsteroidal anti-inflammatory drugs.Should Topical Nonsteroidal Anti-inflammatory Drugs Be Used to Treat Acute Musculoskeletal Conditions? - Corrected ProofLee Wilbur, Rawle Seupaul10.1016/j.annemergmed.2011.06.005Annals of Emergency Medicine (2011)2011-10-10Annals of Emergency Medicine2011-10-10SYSTEMATIC REVIEW SNAPSHOThttp://www.annemergmed.com/article/PIIS0196064411015502/abstract?rss=yesThe training of medical personnel to provide care for disaster victims is a priority for the physician community, the federal government, and society as a whole. Course development for such training guided by well-accepted standardized core competencies is lacking, however. This project identified a set of core competencies and performance objectives based on the knowledge, skills, and attitudes required by the specific target audience (emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel) to ensure they can treat the injuries and illnesses experienced by victims of disasters regardless of cause. The core competencies provide a blueprint for the development or refinement of disaster training courses. This expert consensus project, supported by a grant from the Robert Wood Johnson Foundation, incorporated an all-hazard, comprehensive emergency management approach addressing every type of disaster to minimize the effect on the public's health. An instructional systems design process was used to guide the development of audience-appropriate competencies and performance objectives. Participants, representing multiple academic and provider organizations, used a modified Delphi approach to achieve consensus on recommendations. A framework of 19 content categories (domains), 19 core competencies, and more than 90 performance objectives was developed for acute medical care personnel to address the requirements of effective all-hazards disaster response. Creating disaster curricula and training based on the core competencies and performance objectives identified in this article will ensure that acute medical care personnel are prepared to treat patients and address associated ramifications/consequences during any catastrophic event.Development of National Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians, Nurses, and EMS Professionals - Corrected ProofCarl H. Schultz, Kristi L. Koenig, Mary Whiteside, Rick Murray, National Standardized All-Hazard Disaster Core Competencies Task Force10.1016/j.annemergmed.2011.09.003Annals of Emergency Medicine (2011)2011-10-10Annals of Emergency Medicine2011-10-10DISASTER MEDICINE/CONCEPTShttp://www.annemergmed.com/article/PIIS0196064411016040/abstract?rss=yesHeatstroke is a life-threatening disease; however, no pharmacologic treatment has been proven to be effective. In severe cases with multiple organ dysfunction, the mortality remains high and many patients inevitably develop permanent neurologic damage. We report a near-fatal case of exertional heatstroke with multiple organ dysfunction, including generalized convulsions, acute lung injury, and disseminated intravascular coagulation, successfully treated with induced therapeutic hypothermia (33°C [91.4°F]) by a noninvasive external cooling system. After treatment, the patient completely recovered, without any neurologic sequelae during 1 year of follow-up. To our knowledge, this is the first reported case of using therapeutic hypothermia in heatstroke.Successful Treatment of Severe Heatstroke With Therapeutic Hypothermia by a Noninvasive External Cooling System - Corrected ProofJen-Yee Hong, Yi-Chun Lai, Cheng-Yu Chang, Shih-Chieh Chang, Gau-Jun Tang10.1016/j.annemergmed.2011.09.013Annals of Emergency Medicine (2011)2011-10-10Annals of Emergency Medicine2011-10-10THE PRACTICE OF EMERGENCY MEDICINE/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411015447/abstract?rss=yesOptimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting.Episodes of Care: Is Emergency Medicine Ready? - Corrected ProofJennifer L. Wiler, Dennis Beck, Brent R. Asplin, Michael Granovsky, John Moorhead, Randy Pilgrim, Jeremiah D. Schuur10.1016/j.annemergmed.2011.08.020Annals of Emergency Medicine (2011)2011-09-29Annals of Emergency Medicine2011-09-29HEALTH POLICY/CONCEPTShttp://www.annemergmed.com/article/PIIS0196064411015460/abstract?rss=yesAn increasing percentage of US cocaine has been adulterated with levamisole, an immunomodulator associated with agranulocytosis. We describe 3 emergency department patients with hyponatremia and cocaine use. Despite extensive evaluation, the cause of the hyponatremia was not elucidated but resolved during hospitalization. Because hyponatremia has not previously been associated with cocaine, we sought to uncover a plausible explanation that might be contributing to this new finding. Levamisole was detected in all 3 patients. Although we are unable to confirm causality, we propose that levamisole-adulterated cocaine may have contributed to the hyponatremia described in these patients.Hyponatremia Associated With Levamisole-Adulterated Cocaine Use in Emergency Department Patients - Corrected ProofKerri Friend, Michael C. Milone, Jeanmarie Perrone10.1016/j.annemergmed.2011.08.022Annals of Emergency Medicine (2011)2011-09-29Annals of Emergency Medicine2011-09-29TOXICOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411015496/abstract?rss=yesSEE RELATED ARTICLE, P.■■■. [Ann Emerg Med. 2011;■■:■■■.]The RACE to Where? For What? - Corrected ProofBrendan G. Carr, Judd E. Hollander10.1016/j.annemergmed.2011.09.002Annals of Emergency Medicine (2011)2011-09-29Annals of Emergency Medicine2011-09-29CARDIOLOGY/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411013448/abstract?rss=yesStudy objective: A computed tomography (CT) scan has high sensitivity in detecting intracranial injury in patients with minor head injury but is costly, exposes patients to high radiation doses, and reveals clinically relevant lesions in less than 10% of cases. We evaluate S100-B protein measurement as a screening tool in a large population of patients with minor head injury.Methods: We conducted a prospective observational study in the emergency department of a teaching hospital (Bordeaux, France). Patients with minor head injury (2,128) were consecutively included from December 2007 to February 2009. CT scans and plasma S100-B levels were compared for 1,560 patients. The main outcome was to evaluate the diagnostic value of the S100-B test, focusing on the negative predictive value and the negative likelihood ratio.Results: CT scan revealed intracranial lesions in 111 (7%) participants, and their median S100-B protein plasma level was 0.46 μg/L (interquartile range [IQR] 0.27 to 0.72) versus 0.22 μg/L (IQR 0.14 to 0.36) in the other 1,449 patients. With a cutoff of 0.12 μg/L, traumatic brain injuries on CT were identified with a sensitivity of 99.1% (95% confidence interval [CI] 95.0% to 100%), a specificity of 19.7% (95% CI 17.7% to 21.9%), a negative predictive value of 99.7% (95% CI 98.1% to 100%), a positive likelihood ratio of 1.24 (95% CI 1.20 to 1.28), and a negative likelihood ratio of 0.04 (95% CI 0.006 to 0.32).Conclusion: Measurement of plasma S100-B on admission of patients with minor head injury is a promising screening tool that may be of help to support the clinician's decision not to perform CT imaging in certain cases of low-risk head injury.S100-B Protein as a Screening Tool for the Early Assessment of Minor Head Injury - Corrected ProofDrissa Zongo, Régis Ribéreau-Gayon, Françoise Masson, Magali Laborey, Benjamin Contrand, Louis Rachid Salmi, Danièle Montaudon, Jean Louis Beaudeux, Antoine Meurin, Vincent Dousset, Hugues Loiseau, Emmanuel Lagarde10.1016/j.annemergmed.2011.07.027Annals of Emergency Medicine (2011)2011-09-26Annals of Emergency Medicine2011-09-26TRAUMA/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411014521/abstract?rss=yesStepping into the emergency department (ED) resuscitation room, the emergency medicine resident is immediately confronted with the noise and commotion that often accompany a coding patient. The nurse shuttles around the room grabbing supplies and attaches the monitor leads to the patient. The patient continues to cough and mumble incomprehensible sounds as his mental status further deteriorates. The resident's primary survey reveals that the patient needs to be intubated. He decides to use the Macintosh blade but also prepares the video laryngoscope as a backup. Rapid sequence induction medications are administered, and the resident realizes that this airway is difficult to manage with direct laryngoscopy. He reaches for the video laryngoscope to help him visualize the vocal cords and establish a definitive airway. Sirens from the monitor blare as the oxygen saturation continues to decrease. With beads of sweat forming on his brow, the resident continues to struggle as precious seconds tick away. Desperate, he considers a surgical airway as his last resort and directs the nurse to prepare the patient's neck in anticipation of a cricothyroidotomy. With this decision, the monitors are silenced and the instructor walks into the room. The resident is commended on his efforts, and thus begins the instructional component of this exercise—the debriefing. The key difference in this scenario is that the patient was actually a simulator mannequin and the aforementioned code did not occur in the ED but rather was a form of resident education that occurred in a simulation suite.Emergency Medicine Simulation: A Resident's Perspective - Corrected ProofDavid A. Meguerdichian, Jason D. Heiner, Bradley N. Younggren10.1016/j.annemergmed.2011.08.011Annals of Emergency Medicine (2011)2011-09-26Annals of Emergency Medicine2011-09-26EDUCATION/RESIDENTS' PERSPECTIVEhttp://www.annemergmed.com/article/PIIS0196064411015381/abstract?rss=yesSEE RELATED ARTICLE, P. ■■■.[Ann Emerg Med. 2011;■■:■■■.] In the past 2 decades, the literature has been flooded with studies that attempt to define historical, physical, or laboratory findings that alone or in some combination can be used to risk-stratify emergency department (ED) patients. The rationale for this work is that such risk-stratification tools will identify low-risk patients who do not require additional evaluation during their ED visit. Because the elements of the tool (eg, history, physical, laboratory testing) are typically easier to acquire than the alternative action (eg, computer imaging), the tool will ostensibly decrease use, reduce costs, and avoid adverse effects of the alternate test (eg, consequences of ionizing radiation).Medical Decisionmaking: Let's Not Forget the Physician - Corrected ProofDavid L. Schriger, David H. Newman10.1016/j.annemergmed.2011.08.015Annals of Emergency Medicine (2011)2011-09-26Annals of Emergency Medicine2011-09-26TRAUMA/EDITORIALhttp://www.annemergmed.com/article/PIIS0196064411015368/abstract?rss=yesPhencyclidine is one of the drugs of abuse included in qualitative urine drug screens that are frequently ordered in the emergency department despite concerns about specificity and clinical utility. Many drugs have been described to cause false-positive results for phencyclidine. We present 2 cases of false-positive phencyclidine qualitative urine drug screen results in patients with seizures from tramadol misuse or abuse. The involvement of tramadol and its active metabolite, N-desmethyltramadol, was confirmed by in vitro testing. These cases illustrate that tramadol and its metabolites can trigger a false-positive phencyclidine urine drug screen result in nonfatal cases and highlight the lack of specificity of the phencyclidine qualitative urine drug screen.False-Positive Urine Phencyclidine Immunoassay Screen Result Caused by Interference by Tramadol and Its Metabolites - Corrected ProofBinh T. Ly, Stephen L. Thornton, Colleen Buono, Judith A. Stone, Alan H.B. Wu10.1016/j.annemergmed.2011.08.013Annals of Emergency Medicine (2011)2011-09-19Annals of Emergency Medicine2011-09-19TOXICOLOGY/CASE REPORThttp://www.annemergmed.com/article/PIIS0196064411014090/abstract?rss=yesAfter September 11, 2001, the United States began examining approaches to the delivery of medical care during disasters when demand exceeds available resources. One seemingly popular option is the creation of “crisis” or “altered” care standards meant to reduce the legal standard or duty of care for medical responders. However, evidence supporting the need for reduced care standards is lacking. Concern for liability exists but it is not evidence based. The actual risk for litigation is minimal, according to experience with multiple disasters during the last 15 years. Even if a lower legal standard or duty of care were to be adopted, it is unlikely this would reduce the risk of liability because violation of this lower standard could still result in an allegation of malpractice. Creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate, but altering the legal standard of care will not contribute to this process. Rather than inhibiting the creation of these protocols, the current legal standard of care helps guarantee that disaster policies are created in an ethical and transparent manner. Adoption of a lower legal care standard would encourage implementation of less effective approaches and could undermine the impetus to constantly improve the care of disaster victims. Once lowering the legal standard of care becomes accepted practice, it becomes unclear what will prevent this process from moving downward indefinitely. The most rational approach buttressed by evidence to date supports maintaining the current legal standard of care defined by the actions of reasonably prudent physicians under the same or similar circumstances.Altering the Standard of Care in Disasters—Unnecessary and Dangerous - Corrected ProofCarl H. Schultz, George J. Annas10.1016/j.annemergmed.2011.07.037Annals of Emergency Medicine (2011)2011-09-12Annals of Emergency Medicine2011-09-12DISASTER MEDICINE/CONCEPTShttp://www.annemergmed.com/article/PIIS0196064411013370/abstract?rss=yesStudy objective: Advanced, out-of-hospital procedures such as intravenous access are commonly performed by emergency medical services (EMS) personnel, yet little evidence supports their use among noninjured patients. We evaluate the association between out-of-hospital, intravenous access and mortality among noninjured, non–cardiac arrest patients.Methods: We analyzed a population-based cohort of adult (aged ≥18 years) noninjured, non–cardiac arrest patients transported by 4 advanced life support agencies to one of 16 hospitals from January 1, 2002, until December 31, 2006. We linked eligible EMS records to hospital administrative data and used multivariable logistic regression to determine the risk-adjusted association between out-of-hospital intravenous access and hospital mortality. We also tested whether this association differed by patient acuity by using a previously published, out-of-hospital triage score.Results: Among 56,332 eligible patients, half (N=28,078; 50%) received out-of-hospital intravenous access from EMS personnel. Overall hospital mortality for patients who did and did not receive intravenous access was 3%. However, in multivariable analyses, the placement of out-of-hospital, intravenous access was associated with an overall reduction in odds of hospital mortality (odds ratio=0.68; 95% confidence interval [CI] 0.56 to 0.81). The beneficial association of intravenous access appeared to depend on patient acuity (P=.13 for interaction). For example, the odds ratio of mortality associated with intravenous access was 1.38 (95% CI 0.28 to 7.0) among patients with lowest acuity (score=0). In contrast, the odds ratio of mortality associated with intravenous access was 0.38 (95% CI 0.17 to 0.9) among patients with highest acuity (score ≥6).Conclusion: In this population-based cohort, out-of-hospital efforts to establish intravenous access were associated with a reduction in hospital mortality among noninjured, non–cardiac arrest patients with the highest acuity. Reasons why this occurred (cause and effect) could not be determined in this model.Intravenous Access During Out-of-Hospital Emergency Care of Noninjured Patients: A Population-Based Outcome Study - Corrected ProofChristopher W. Seymour, Colin R. Cooke, Paul L. Hebert, Thomas D. Rea10.1016/j.annemergmed.2011.07.021Annals of Emergency Medicine (2011)2011-08-29Annals of Emergency Medicine2011-08-29EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCHhttp://www.annemergmed.com/article/PIIS0196064411006767/abstract?rss=yesDecisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the “greatest good for the greatest number” to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.Allocating Scarce Resources in Disasters: Emergency Department Principles - Corrected ProofJohn L. Hick, Dan Hanfling, Stephen V. Cantrill10.1016/j.annemergmed.2011.06.012Annals of Emergency Medicine (2011)2011-08-22Annals of Emergency Medicine2011-08-22DISASTER MEDICINE/CONCEPTS