The American journal of emergency medicine
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In the daily practice of emergency medicine, physicians constantly interact with components of emergency medical services systems. The provision of high-quality care in the prehospital setting requires emergency physicians to remain abreast of recent literature that may inform the care of patients prior to their arrival at the emergency department. This literature review will examine some recent trends in the prehospital literature. In addition, the review will highlight important areas of clinical practice which represent some of the many intersections between emergency medicine and emergency medical services such as cardiac arrest and airway management.
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Idarucizumab is a monoclonal antibody fragment specifically targeted to dabigatran. It has demonstrated prompt and durable reversal of the anticoagulant effects of dabigatran in animal studies and phase 1 studies of young, elderly, and renally impaired volunteers. Although elective invasive procedures and most bleeding complications in dabigatran-treated patients can be managed by temporarily stopping dabigatran therapy and using supportive measures, there are rare clinical situations that require urgent reversal of the anticoagulant effect of dabigatran. ⋯ Supported by these interim results, idarucizumab has been approved in the United States and the European Union for use when reversal of the anticoagulant effects of dabigatran is needed for emergency surgery/urgent procedures or in patients with life-threatening or uncontrolled bleeding. Clinical use of idarucizumab should follow the same processes as patient enrollment in this study, which is projected to be completed in 2016. The outcomes achieved with this specific reversal agent are likely to be of continued interest to treating physicians.
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Patients taking direct oral anticoagulants (DOACs) who then need an emergency invasive procedure require specialized management strategies. Appropriate patient evaluation includes assessment of the current anticoagulation state, including timing of the last dose. DOACs require particular coagulation assays to measure anticoagulation levels accurately, although standard coagulation screening tests may provide qualitative guidance. ⋯ Idarucizumab can streamline the pre- and periprocedural anticoagulation management of dabigatran-treated patients, as it provides fast, complete, and sustainable reversibility. Andexanet alfa is an inactive, decoy factor Xa (FXa) molecule that binds FXa inhibitors, and ciraparantag is a synthetic molecule designed to bind fractionated and unfractionated heparins, and each of the currently approved DOACs. As clinical development of the additional anti-FXa-specific anticoagulant reversal agents proceeds, the respective role of each in the management of emergency bleeding events and invasive procedures will be better defined, and it is hoped they will make important contributions to patient care.
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Outpatient management of atrial fibrillation can be a safe alternative to inpatient admission after emergency department (ED) visits. We aim to describe trends and predictors of hospital admission for atrial fibrillation and determine the variation in admission among US hospitals. ⋯ From 2006 to 2011, ED visits for atrial fibrillation in the United States increased by almost a third, with a minimal change in ED admission rates. One-fifth of variation in admission rates is due to hospital site and not explained by hospital characteristics. Hospital-specific practice patterns may identify opportunities to increase outpatient management.
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We examined whether the values obtained from principal component analysis (PCA) on laboratory tests can be used to predict bacterial infections and identify bacterial strains in blood culture (BC). ⋯ The present results obtained by PCA on laboratory tests involving PCT, PLT, white blood cell, and CRP suggest the potential of PCA-obtained values to not only predict bloodstream infection but also identify bacterial strains. This provides some clinical significance in the management of sepsis in acute care.