Internal and emergency medicine
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Review
The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department.
Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the "classic triad" of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10-15% of cases. ⋯ Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a "classic triad" screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.
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This study aims to evaluate the mobile emergency severity index (ESI) tool in terms of validity compared with the original ESI triage. The original ESI and mobile ESI were used with patients at the Department of Emergency Medicine, Ramathibodi Hospital, Thailand. Eligible patients were evaluated by sixth-year medical students/emergency physicians using either the original or mobile ESI. ⋯ The highest kappa in the original ESI group is 0.69, comparing emergency physicians vs gold standard, while the lowest kappa in the application group is 0.84 comparing the medical students vs gold standard. Both medical students and emergency physicians are more confident with the mobile ESI application triage. In conclusion, the mobile ESI has better inter-rater reliability, and is more user-friendly than the original paper form.
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Observational Study
Failure to achieve first attempt success at intubation using video laryngoscopy is associated with increased complications.
The purpose of this investigation was to investigate the association between first attempt success and intubation-related complications in the Intensive Care Unit after the widespread adoption of video laryngoscopy. We further sought to characterize and identify the predictors of complications that occur despite first attempt success. This was a prospective observational study of consecutive intubations performed with video laryngoscopy at an academic medical Intensive Care Unit. ⋯ Pre-intubation predictors of at least one complication despite first attempt success include vomit or edema in the airway as well as the presence of hypoxemia or hypotension. There are increased odds of complications with even a second attempt at intubation in the Intensive Care Unit. Complications occur frequently despite a successful first attempt, and as such, the goal of airway management should not be simply first attempt success, but instead first attempt success without complications.
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We determine the frequency of initial misdiagnosis and inappropriate treatment with antiplatelets/anticoagulants in the emergency department (ED) and the resultant clinical outcomes in patients with acute type A aortic dissection (AAOD). Medical records of patients with a final diagnosis of AAOD admitted from March 2004 through October 2015 to our tertiary-level heart hospital were evaluated. Patients with suspected dissection in ED were compared to those with initial misdiagnosis regarding demographics and clinical presentation, laboratory and echocardiographic findings. ⋯ Initial misdiagnosis of AAOD is a common problem. Hospital mortality is not significantly affected by receiving antiplatelets/anticoagulants. Although long-term mortality is higher in patients with initial misdiagnosis, it is not an independent predictor for long-term mortality.