J Emerg Med
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In 2015, the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission launched the sepsis core measures in an attempt to decrease sepsis morbidity and mortality. Recent studies call into question the multiple treatment measures in early goal-directed therapy on which these CMS measures are based. ⋯ There was no difference in the mortality rate of patients with a final diagnosis of sepsis. However, there was a significant increase in the utilization of resources to care for these patients. As a result of the overutilization of these resources, the cost for both patients and hospitals has increased without improvement in mortality.
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Most patients transferred from a non-percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes. ⋯ In our region, STEMI patients can be diagnosed accurately and transported safely on bypass to a PCI center for primary PCI while respecting target reperfusion times.
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Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. ⋯ Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.
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Orbital cellulitis is an uncommon ophthalmological emergency in children, but rapid emergency department (ED) diagnosis is essential. ⋯ A 13-year-old boy presented to our pediatric ED with left orbital cellulitis secondary to pansinusitis. Emergency bedside ocular ultrasonography was used to evaluate and expedite his management. Besides inflammatory changes observed on ultrasound of his affected orbit, the patient had an elevated optic disc height and increased nerve sheath diameter, which were not commonly reported in published literature on orbital cellulitis. Emergent computed tomography of the orbits and head showed orbital cellulitis without complications of orbital abscess or cavernous sinus thrombosis. Despite initiating early appropriate antibiotics, there was rapid progression of his disease and he developed intraconal abscess and cavernous sinus thrombosis the following day. After emergency surgical drainage of his pansinusitis, antibiotics, and anticoagulation, he was discharged well after a 2-week hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There are important advantages of using bedside ultrasonography for diagnosis of pediatric orbital cellulitis in the ED setting. Further research should be done to evaluate the clinical significance of an enlarged optic nerve sheath diameter and raised optic disc height in pediatric orbital cellulitis.
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Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse. ⋯ Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.