European journal of emergency medicine : official journal of the European Society for Emergency Medicine
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Randomized Controlled Trial
A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.
A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely. ⋯ Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.
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Patients commonly present to the Emergency Department with sudden onset acute severe headache, but exclusion of significant secondary causes, particularly subarachnoid haemorrhage (SAH), is vital. The misdiagnosis of SAH is most likely in patients with a normal neurological examination, and the consequences can be disastrous. A noncontrast computed tomography (CT) brain scan is the initial investigation of choice, and most would recommend that, if negative, this be followed by a lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis. Many hospitals in the UK have developed Clinical Decision Unit (CDU) pathways to provide a standardized approach to the investigation and management of neurologically normal patients with headache suggestive of SAH. ⋯ The management of neurologically pristine patients with sudden onset severe headache on a CDU pathway is feasible. In light of the low prevalence of SAH in this population, the decision to follow a negative CT with an LP in all cases needs careful consideration, as CSF results may only rarely confer therapeutic benefit to patients suspected of SAH.
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Observational Study
Hemostatic dressings in civil prehospital practice: 30 uses of QuikClot Combat Gauze.
To report the use and describe the interest of hemostatic dressings in a civilian setting, we provided medical prehospital teams with QuikClot Combat Gauze (QCG) and asked physicians to complete a specific questionnaire after each use. Thirty uses were prospectively reported. The wounds were mostly caused by cold steel (n=15) and were primarily cervicocephalic (n=16), with 19/30 active arterial bleedings. ⋯ The application of QCG permitted the removal of an effective tourniquet that was applied initially for three patients. No side-effects were reported. The provision of hemostatic dressings in civilian resuscitation ambulances was useful by providing an additional tool to limit bleeding while rapidly transporting the injured patient to a surgical facility.
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Review Practice Guideline
How to manage patients on rivaroxaban in the emergency department: a statement of the Italian society of emergency medicine advisory board.
Rivaroxaban, a new oral anticoagulant, has been approved in many countries and its everyday use in clinical practice is increasing. Thus, the chances for an emergency physician to encounter rivaroxaban-treated patients in emergency situations have increased. Here, the authors address the main issues in terms of the prescription of rivaroxaban and the management of these patients in cases of minor or major bleeding, urgent surgery, atrial fibrillation requiring cardioversion, acute ischemic stroke, ST-elevation myocardial infarction, and new onset of atrial fibrillation in recent ST-elevation myocardial infarction. The recommendations reached are based on a literature review and a panel discussion of the advisory board of SIMEU, the Italian Society of Emergency Medicine.