J Emerg Med
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Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs. ⋯ Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.
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It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids can lead to nausea and vomiting when used alone. Therefore, antiemetics are often given prophylactically with opioids for nausea and vomiting in the emergency department (ED). This systematic review evaluates the use of prophylactic antiemetics with parenteral opioids for the treatment of acute pain in the ED. ⋯ Based on the literature review, routine use of prophylactic antiemetics are not indicated with administration of parenteral opioids for treatment of acute pain in the ED, as nausea and vomiting are infrequent side effects. The recent literature clearly demonstrates that there are potential undesirable side effects from the use of antiemetics when using opioids. However, one subgroup of patients, those with a known history of nausea and vomiting after opioid use or a history of travel sickness, may benefit from the use of prophylactic antiemetic when being treated with parenteral opioids.
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Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. ⋯ Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
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Case Reports
Catecholaminergic Polymorphic Ventricular Tachycardia: Challenges During Resuscitation and Post-Cardiac Arrest Care.
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare channelopathy involving cardiac calcium metabolism that often shows up at an early age with misleading clinical symptoms, such as emotion- or exercise-related syncope with a normal resting electrocardiogram. In addition, it might be the underlying cause of sudden cardiac arrest in children or young adults. The particular pathophysiology of CPVT makes it particularly challenging for both resuscitation and the subsequent intensive care management after return of spontaneous circulation (ROSC). ⋯ We describe a case of sudden cardiac arrest in an 11-year-old girl affected by CPVT, with a particular focus on the most challenging aspects of resuscitation and intensive care management in light of other experiences found in the literature. A warning about the prodysrythmicity of mild hypothermia induced in the context of post-ROSC targeted temperature management in this particular population of patients and its possible physiopathological basis are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CPVT is a rare but potentially lethal cause of stress-related syncope and sudden cardiac arrest in children and young adults. The diagnosis of CPVT requires a high level of suspicion and an interdisciplinary approach, including some adjustments during resuscitation and post-cardiac arrest care.
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Inhaled β-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. ⋯ This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people's ability to use, and presumably to instruct patients/parents in proper use of, MDIs.