The American journal of emergency medicine
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The objective of the study was to evaluate how often intravenous (IV) fosphenytoin is used when oral phenytoin loading is possible. The methods included a retrospective chart review of all patients receiving IV fosphenytoin in the emergency department. We prospectively derived criteria that identify patients with seizures who could receive oral phosphenytoin loading (awake on arrival, alert, no emesis, and lack of endotracheal intubation, repeated seizures, or status epilepticus after arrival). ⋯ The remaining 25 (45%, 95% confidence interval 32%-59%) patients could have been loaded orally with phenytoin. In a single institution, fosphenytoin administration is inappropriate almost half the time. Oral phenytoin loading is less expensive and safe.
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Wrist injuries are frequently encountered in the emergency department. When a patient presents with such an injury, the possibility of scaphoid fracture must be at the top of the differential for the emergency practitioner. ⋯ The emergency physician needs to be vigilant for scaphoid fracture and be aggressive in both its diagnosis and treatment to avoid this practice pitfall. This review examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician.
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Ultrasound is the imaging study of choice for the detection of gallstones, but ultrasound through medical imaging departments (MI Sono) is not readily available on an immediate basis in many emergency departments (EDs). Several studies have shown that emergency physicians can perform ultrasound themselves (ED Sono) to rule out gallstones with acceptable accuracy after relatively brief training periods, but there have been no studies to date specifically addressing the effect of ED Sono of the gallbladder on quality and cost-effectiveness in the ED. In this study, we investigated measures of quality and cost-effectiveness in evaluating patients with suspected symptomatic cholelithiasis during three different years with distinctly different approaches to ultrasound availability. ⋯ We conclude that greater availability of MI Sono in the ED was associated with improved quality in the evaluation of patients with suspected symptomatic cholelithiasis but also with increased ultrasound costs. The availability of ED Sono in addition to readily available MI Sono was associated with further improved quality and decreased costs. The indeterminate rate for ED Sono was relatively high, but excluding indeterminates, the accuracy of ED Sono was comparable with published reports of MI Sono.
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Multicenter Study
Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels.
This study's objective was to analyze whether the quantity of free intraperitoneal fluid on ultrasonography, alone or in combination with unstable vital signs, is sensitive in determining the need for laparotomy in patients presenting with blunt trauma. Adult patients who presented with blunt abdominal trauma to 2 level I trauma centers were enrolled. Combined intraperitoneal fluid levels (anechoic stripe) of 5 intraperitoneal areas were measured and defined as small (< 1.0 cm), moderate (> 1.0 cm, < 3.0 cm), or large (> 3.0 cm). ⋯ Of the 18 patients with a large fluid accumulation, 16 underwent exploratory laparotomy (89% sensitivity), and all 8 patients with unstable vital signs underwent exploratory laparotomy (100% sensitivity). Of the 10 patients with a moderate fluid accumulation, 6 underwent exploratory laparotomy (60% sensitivity), and 4 of the 6 patients with unstable vital signs underwent exploratory laparotomy (67% sensitivity). A large intraperitoneal fluid accumulation on ultrasonography in combination with unstable vital signs, is sensitive for determining the need for exploratory laparotomy in patients presenting with blunt trauma.
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Comparative Study
Voice recognition software versus a traditional transcription service for physician charting in the ED.
This study was conducted to compare real-time voice recognition software to a traditional transcription service. Two emergency department (ED) physicians dictated 47 charts using a voice dictation software program and a traditional transcription service. Accuracy, word per minute dictation time and turnaround time were calculated from the data. ⋯ The charts dictated using the voice recognition program were considerably less costly than the manually transcribed charts. In summary, computer voice recognition is nearly as accurate as traditional transcription, it has a much shorter turnaround time and is less expensive than traditional transcription. We recommend its use as a tool for physician charting in the ED.