The American journal of emergency medicine
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The aim of the present study was, first, to evaluate the prognostic value of mid-regional proadrenomedullin (proADM) in emergency department (ED) patients with a diagnosis of community acquired pneumonia (CAP) and, second, to analyze the added value of proADM as a risk stratification tool in comparison with other biomarkers and clinical severity scores. We evaluated proADM, C-reactive protein and procalcitonin, along with the Pneumonia Severity Index (PSI) score in consecutive CAP patients. Ability to predict 30-day mortality was assessed using receiver operating characteristic curve analysis, logistic regression, and reclassification metrics for all patients and for patients with high PSI scores. ⋯ ROC(AUC) (area under the receiver operating characteristic curve) was higher for proADM than for PSI score (ROC(AUC) [95% CI], 0.810 [0.654-0.965] and 0.669 [0.445-0.893] respectively). Reclassification analysis revealed that combination of PSI and proADM allows a better risk assessment than PSI alone (P = .001). MR-proADM may be helpful in individual risk stratification of CAP patients with a high PSI score in the ED, allowing to a better identification of patients at risk of death.
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Severe malaria complicated by circulatory shock is known as algid malaria. Cases of severe imported malaria are seen increasingly frequently in emergency departments in the United States, Europe, and other locales. The optimal volume resuscitation strategy for patients with severe malaria is not well-defined. ⋯ Although not identical, the late inflammatory response in severe malaria leading to capillary permeability shares many similarities with the immunologic response in bacterial sepsis. Our case report discusses a patient with severe imported malaria complicated by shock, successfully managed with large-volume fluid resuscitation, hemodynamic optimization, early antimalarial agents, and broad-spectrum antibiotics. This report questions the strategy of cautious fluid resuscitation in algid malaria and suggests that case series comparing goal-directed resuscitation to historic controls along with prospective multicenter controlled trials should be conducted to determine the best fluid resuscitation strategy.
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Posterior sternoclavicular dislocation is a rare injury that must be recognized by the emergency physician because failure to rapidly reduce can lead to serious vascular complications. A high index of suspicion must be maintained in the appropriate setting because these injuries are difficult to detect on physical examination as well as on plain radiography. We present a case of a 19-year-old man with an isolated posterior sternoclavicular dislocation, in the setting of minor blunt trauma. The correct diagnosis required multiple imaging modalities over 2 emergency department visits and was ultimately successfully managed with intraoperative reduction.
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The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use. ⋯ Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.
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End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis.
Exhaled end-tidal carbon dioxide (ETCO(2)) concentration is associated with lactate levels in febrile patients. We assessed the association of ETCO(2) with mortality and lactate levels in patients with suspected sepsis. ⋯ We observed a significant association between ETCO(2) concentration and in-hospital mortality in emergency department patients with suspected sepsis across a range of disease severity.