Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Current guideline recommendations for optimal management of nonpurulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is a lack of evidence to guide emergency physicians regarding selection of patients for oral versus intravenous antibiotic therapy. The primary objective was to identify predictors associated with oral antibiotic treatment failure. ⋯ We identified 500 patients (mean ± SD age = 64 ± 19 years, 279 male [55.8%], and 126 [25.2%] with diabetes). Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR] = 6.31, 95% confidence interval [CI] = 1.80 to 22.08), chronic ulcers (OR = 4.90, 95% CI = 1.68-14.27), history of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection (OR = 4.83, 95% CI = 1.51 to 15.44), and cellulitis in the past 12 months (OR = 2.23, 95% CI = 1.01 to 4.96) were independently associated with oral antibiotic treatment failure CONCLUSION: This is the first study to evaluate predictors of oral antibiotic treatment failure for nonpurulent SSTIs treated in the ED. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for outpatient management of nonpurulent SSTIs.
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Review Meta Analysis
Ultrasound-assisted Lumbar Punctures: A Systematic Review and Meta-Analysis.
Lumbar punctures (LPs) are a common procedure in emergency medicine. However, studies have found that failed procedure rates can be as high as 50%. Ultrasound has been suggested to improve success rates by visually identifying the location and trajectory for the LP procedure. This systematic review and meta-analysis was performed to determine whether the use of ultrasound improved the rate of successful LP performance. ⋯ Ultrasound-assisted LPs were associated with higher success rates, fewer traumatic LPs, shorter time to successful LP, fewer needle passes, and lower patient pain scores. Ultrasound should be considered prior to performing all LPs, especially in patients with difficult anatomy. Further studies are recommended to determine whether this effect is consistent in both adult and pediatric subgroups, as well as the impact of transducer type and body habitus on this technique.
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Randomized Controlled Trial
The HEART Pathway Randomized Controlled Trial One-year Outcomes.
The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. ⋯ The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.
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This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). ⋯ The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.