The American journal of emergency medicine
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Multicenter Study
Pediatric firearm injuries and socioeconomic vulnerability before and during the COVID-19 pandemic.
Pediatric firearm injuries disproportionately affect groups experiencing socioeconomic disadvantage. Firearm injuries increased during the COVID-19 pandemic, but the impact on communities by degree of socioeconomic disadvantage is unknown. We examined the association between socioeconomic vulnerability and change in pediatric firearm injuries before versus during the pandemic. ⋯ The increase in pediatric firearm injuries during the COVID-19 pandemic impacted youth in all but the lowest deprivation quartile. Efforts at curbing gun violence should identify and amplify protective effects in under-resourced communities.
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Ketamine is an NMDA receptor antagonist commonly used as a dissociative anesthetic and analgesic. Though it is conventionally administered via the intravenous, intramuscular, or intranasal route, use as a compounded analgesic cream is becoming increasingly common. This is a case report of a 61-year-old man who was detained by the police for erratic driving. ⋯ His clinical presentation was consistent with ketamine toxicity, and mass spectrometry demonstrated an elevated urine ketamine concentration (32,300 ng/mL). His symptoms resolved spontaneously within a few hours and he was discharged. This is a unique case of systemic toxicity following dermal application of a ketamine pain cream in a patient with impaired skin barrier function due to pyoderma gangrenosum.
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Transfer of patients between hospitals is common, costly, and over 20 % are estimated to be avoidable, meaning patients do not receive specialized interventions once transferred. Older adults are more likely to be transferred and may be at increased risk for developing delirium or other complications due to transfer. We aimed to determine the frequency of potentially avoidable transfer (PAT) among older adults; identify conditions most likely to involve a PAT; and describe factors associated with PAT. ⋯ PATs were common in transfers of older adults, particularly among a subset of neurologic, cardiovascular, and injury-related conditions. These conditions may represent ideal targets for intervention to decrease rates of avoidable transfer. Research exploring hospital variation in transfer practices and the impact of PAT on older adults' health outcomes are also needed.
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We conducted an explanatory, sequential mixed-methods study to measure variation in the use of imaging and physical therapy (PT) for acute low back pain (LBP) and to identify implementation determinants that might explain variation in use across 22 EDs and 27 urgent cares in urban and rural locations within a community-based health system. ⋯ Guideline concordance for use of imaging and PT varied substantially across physicians and advance practice providers providing care at EDs and UC centers within a community-based health system. Implementation strategies that address barriers identified by this study, including varied understanding of the PT discipline, complex workflows for placing PT referrals, the medico-legal assurance that imaging provides, and the lack of feedback loops in ED and UC centers should be tested in future hybrid implementation-effectiveness trials to increase concordance to LBP guidelines and minimize harm related to overuse of imaging and underuse of conservative first-line treatment approaches.
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Fentanyl use has been linked with an increasing number of opioid-related deaths. The emergency department (ED) is a critical contact point for patients with opioid use disorder (OUD) to access basic healthcare. Little information is known about buprenorphine precipitated opioid withdrawal (BPOW). This study sought to examine the rates of BPOW in patients who used fentanyl and received buprenorphine in the ED. ⋯ We demonstrate that the prevalence of BPOW is low in a cohort of patients who use fentanyl. When precipitated withdrawal does occur, however, it can be severe and require intensive treatment, ICU admission, and prolonged hospital stay.