J Emerg Med
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Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US. ⋯ An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.
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In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation. ⋯ The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.
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Immune checkpoint inhibitors (ICIs) have a wide range of toxicities affecting potentially any organ system stemming from increased activity within the T-cell lineage similar to that observed in autoimmunity. ⋯ A 57-year-old man with metastatic papillary renal cell carcinoma treatment with combination ICI therapy presented with a history of rapidly progressive diplopia. Neurological examination revealed bilateral fatigable ptosis and asymmetrical ophthalmoplegia. His clinical findings were in keeping with an immune-mediated myasthenia gravis. He was immediately commenced on 1 mg/kg of intravenous methylprednisolone and pyridostigmine 60 mg 3 times a day. On day 2 of admission he was given 1 g/kg of intravenous immunoglobulins. He made a rapid and full clinical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Immune-mediated myasthenia gravis is an important toxicity of ICIs. Early recognition and treatment of this presentation may reduce the significant morbidity and mortality associated with it.
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Most pediatric resuscitator bags are equipped with a positive-pressure relief ("pop-off") valve meant to prevent delivery of excessive pressure. Pop-off valves, however, can lead to adverse events in emergency situations when providers are unaware of their significance. ⋯ A 3-year-old girl with muscular atrophy and a chronic tracheostomy tube was noted to have decreasing oxygen saturations. Paramedics found the patient in cardiac arrest and initiated resuscitative efforts; the patient regained pulses but quickly became pulseless again. There were two more cycles of cardiac arrest followed by return of spontaneous circulation. When she arrived at the emergency department pulses were present. The emergency physician performed bag ventilation and felt no resistance to bag squeezing, but saw no chest rise, and realized the patient was not being ventilated because all of the air was escaping through the pop-off valve. When the valve was closed, it was impossible to perform bag ventilation. She was found to have complete occlusion of her tracheostomy tube; the paramedics had not been ventilating during transport, though were unaware of the occlusion because of the open pop-off valve. Removal of the tracheostomy tube and placement of an endotracheal tube significantly improved ventilation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pop-off valves are common on pediatric resuscitator bags, but often result in insufficient ventilation and oxygenation during emergency airway management. Emergency airway experts recommend that pop-off valves be avoided or deactivated during emergency resuscitation, but this information has not been widely disseminated.
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Trauma providers seek to accurately assess the risk of patients with abdominal seat belt sign (ASBS). As hospital costs continue to rise, identification of strategies to safely discharge emergency department (ED) patients has become crucial. ⋯ This study shows that ED trauma patients with significant seat belt abrasion or contusion can have IAI. With the very high sensitivity of modern abdominal CT scanners, clinicians could consider safe ED discharge of stable ASBS patients while providing strong return precautions. Our large cohort strengthens the evidence on decision-making in ASBS patients to ensure outcomes and use of health care resources.