Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best-practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. ⋯ We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients.
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Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need. ⋯ This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.
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Review Meta Analysis
Prehospital Noninvasive Ventilation for Acute Respiratory Failure: Systematic Review, Network Meta-analysis, and Individual Patient Data Meta-analysis.
This meta-analysis aimed to determine the effectiveness of prehospital continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP) in acute respiratory failure. ⋯ Prehospital CPAP can reduce mortality and intubation rates compared to standard care, while the effectiveness of prehospital BiPAP is uncertain.
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Review Meta Analysis
Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department.
Pregnancy causes a small increase in risk of venous thromboembolism (VTE), but a large increase in concern upon presentation to an emergency department (ED) with symptoms of pulmonary embolism (PE), which may cause physicians to employ a low test threshold. This was a systematic review with the hypothesis that symptomatic pregnant patients in the ED have a low relative risk (RR) for VTE outcome. ⋯ In the ED setting, physicians test for PE in pregnant patients at a low threshold, resulting in a low rate of VTE diagnosis and a RR of VTE that is lower than that for nonpregnant women of childbearing age who are tested for PE in the ED setting.
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The objective was to evaluate the diagnostic test characteristics of three validated electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) in undifferentiated, asymptomatic emergency department (ED) patients with hypertension (HTN). ⋯ In this cohort of predominately African American ED patients with asymptomatic HTN, sensitivity and specificity of standard ECG criteria were relatively poor for the diagnosis of LVH on echocardiography. Thus, ECG is of limited use for LVH risk stratification in asymptomatic ED patients with elevated blood pressure, with additional clinical information only modestly strengthening its predictive value.