Annals of emergency medicine
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The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. ⋯ The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.
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We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. ⋯ The ACA's Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA's effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians.
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Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. ⋯ Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.
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Loperamide is a nonprescription opioid widely used for the treatment of diarrhea. Although it is relatively safe at therapeutic doses, increasing reports describe its misuse and abuse at very high doses either for euphoric effects or to attenuate symptoms of opioid withdrawal. Life-threatening loperamide toxicity can result from the relatively new clinical syndrome of loperamide-induced cardiac toxicity. ⋯ Features of conventional opioid toxicity may also be present. The mainstays of treatment include advanced cardiac life support and supportive care, although selected patients may be candidates for overdrive pacing, intravenous lipid emulsion, or extracorporeal membrane oxygenation. In patients who survive loperamide toxicity, consideration should be given to the treatment of an underlying opioid use disorder, if present.
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Multicenter Study
Analysis of Emergency Department Length of Stay for Mental Health Patients at Ten Massachusetts Emergency Departments.
Prolonged boarding times in the emergency department (ED) disproportionately affect mental health patients, resulting in patient and provider dissatisfaction and increased patient morbidity and mortality. Our objective is to quantify the burden of mental health boarding and to elucidate the effect of insurance together with demographic, social, and comorbid factors on length of stay. ⋯ Mental health patients in Massachusetts have lengthy ED visits, particularly those requiring inpatient admission. Boarding time accounts for the majority of total ED length of stay and varies by insurance, even when other factors known to affect ED length of stay are controlled. Efforts to improve timeliness of care for mental health emergencies should focus on reducing ED boarding and eliminating disparities in care by insurance status.