No abstract available.

No abstract available.
Emergencies* ; Emergency Medicine*

Lacerations are a common reason for patients to seek medical attention, and are often acutely managed in the emergency department. Recent studies pertaining to closure techniques, sedation and analgesia, advances in wound care, and various other topics have been published, which may enhance our understanding of this injury and improve our management practices. This article will review pertinent studies published in the past few years relevant to laceration management. Understanding the current literature and appreciating which areas warrant further investigation will help us optimize outcomes for patients who sustain laceration injuries.
Analgesia ; Emergencies ; Emergency Medicine ; Emergency Service, Hospital ; Humans ; Lacerations ; Wounds and Injuries

PURPOSE: In this study, we determined the long-term effects of the Independent Capacity Protocol (ICP), in which the emergency department (ED) is temporarily used to stabilize patients, followed by transfer of patients to other facilities when necessary, on crowding metrics. MATERIALS AND METHODS: A before and after study design was used to determine the effects of the ICP on patient outcomes in an academic, urban, tertiary care hospital. The ICP was introduced on July 1, 2007 and the before period included patients presenting to the ED from January 1, 2005 to June 31, 2007. The after period began three months after implementing the ICP from October 1, 2007 to December 31, 2010. The main outcomes were the ED length of stay (LOS) and the total hospital LOS of admitted patients. The mean number of monthly ED visits and the rate of inter-facility transfers between emergency departments were also determined. A piecewise regression analysis, according to observation time intervals, was used to determine the effect of the ICP on the outcomes. RESULTS: During the study period the number of ED visits significantly increased. The intercept for overall ED LOS after intervention from the before-period decreased from 8.51 to 7.98 hours [difference 0.52, 95% confidence interval (CI): 0.04 to 1.01] (p=0.03), and the slope decreased from -0.0110 to -0.0179 hour/week (difference 0.0069, 95% CI: 0.0012 to 0.0125) (p=0.02). CONCLUSION: Implementation of the ICP was associated with a sustainable reduction in ED LOS and time to admission over a six-year period.
Aged ; *Clinical Protocols ; *Crowding ; Efficiency, Organizational ; Emergency Service, Hospital/*organization & administration/utilization ; Female ; Hospital Planning/*methods ; Hospitals, Urban/*organization & administration/utilization ; Humans ; Length of Stay/*statistics & numerical data ; Male ; Outcome and Process Assessment (Health Care) ; Patient Admission/statistics & numerical data ; Patient Transfer/statistics & numerical data ; Regression Analysis ; Time ; Time Factors ; Triage

Objective: Four-factor prothrombin complex concentrate (4F-PCC) was approved by the US Food and Drug Administration in 2013 for management of severely bleeding patients on warfarin therapy. We describe use of 4F-PCC at a large, suburban academic center. Methods: We retrospectively reviewed all patients receiving 4F-PCC from its introduction through 2016 at a large level 1 trauma center. Clinical and demographic data were obtained, including indications for anticoagulation and antiplatelet agents, comorbidities, concomitant medications, etiology and site of bleeding, as well as disposition, length of stay, mortality, and thrombotic events. Results: One hundred eighty-four patients received 4F-PCC. Mean age was 72 years; 40.8% were female. Indications for 4F-PCC administration included: active bleeding (74%), reversal prior to a procedure (14%), and elevated international normalized ratio (12%). Warfarin was the most common concomitant medication (71.1%). Most patients were receiving anticoagulation for atrial fibrillation (63%). Concomitant treatments for bleeding included vitamin K (58.2%), packed red blood cells (50%), fresh frozen plasma (38%), and platelets (26.1%), amongst others. Median length of hospital stay was 8.4 days. Nine patients (4.9%) developed thrombosis within 90 days of 4F-PCC. Mortality was 24.5%, with notably higher rates amongst those who received 4F-PCC for off-label indications (19.1% on-label mortality vs. 37.7% off-label mortality on chi-square analysis, P=0.01). Conclusion This study demonstrates that 4F-PCC is being utilized for indications other than the reversal of warfarin-induced coagulopathy. Further investigation is warranted to determine the efficacy and safety of 4F-PCC for these potential indications.

Objective: Four-factor prothrombin complex concentrate (4F-PCC) was approved by the US Food and Drug Administration in 2013 for management of severely bleeding patients on warfarin therapy. We describe use of 4F-PCC at a large, suburban academic center. Methods: We retrospectively reviewed all patients receiving 4F-PCC from its introduction through 2016 at a large level 1 trauma center. Clinical and demographic data were obtained, including indications for anticoagulation and antiplatelet agents, comorbidities, concomitant medications, etiology and site of bleeding, as well as disposition, length of stay, mortality, and thrombotic events. Results: One hundred eighty-four patients received 4F-PCC. Mean age was 72 years; 40.8% were female. Indications for 4F-PCC administration included: active bleeding (74%), reversal prior to a procedure (14%), and elevated international normalized ratio (12%). Warfarin was the most common concomitant medication (71.1%). Most patients were receiving anticoagulation for atrial fibrillation (63%). Concomitant treatments for bleeding included vitamin K (58.2%), packed red blood cells (50%), fresh frozen plasma (38%), and platelets (26.1%), amongst others. Median length of hospital stay was 8.4 days. Nine patients (4.9%) developed thrombosis within 90 days of 4F-PCC. Mortality was 24.5%, with notably higher rates amongst those who received 4F-PCC for off-label indications (19.1% on-label mortality vs. 37.7% off-label mortality on chi-square analysis, P=0.01). Conclusion This study demonstrates that 4F-PCC is being utilized for indications other than the reversal of warfarin-induced coagulopathy. Further investigation is warranted to determine the efficacy and safety of 4F-PCC for these potential indications.

OBJECTIVE: Introduction of target specific anticoagulants and recent guidelines encourage outpatient management of low risk patients with venous thromboembolism. We describe hospital admission rates over time for patients presenting to US emergency departments (EDs) with deep vein thrombosis (DVT) and pulmonary embolism (PE) and estimate the proportion of low-risk PE patients who could potentially be managed as outpatients. METHODS: We performed a structured analysis of the National Hospital Ambulatory Medical Care Survey (a nationally representative weighted sampling of US ED visits) database for the years 2006–2010 including all adult patients with a primary diagnosis of DVT or PE. Simplified pulmonary embolus scoring index (sPESI) scores were determined in patients with PE to identify low risk patients. RESULTS: There were an estimated 652,000 and 394,000 ED visits for DVT and PE over the 5-year period (0.17%). Mean (SE) age was 59 (1.3), 50% were female, and 40% were > 65 years. Admission rates for DVT and PE were 52% and 90% respectively with no significant changes over time. In patients with DVT, predictors for admission were age (odds ratio, 1.03 per year of age [95% confidence interval, 1.01 to 1.05]) and race (odds ratio, 4.1 [95% confidence interval, 0.9 to 19.8] for Hispanics and 2.9 [1.2 to 7.4] for Blacks). Of all ED patients with PE, 51% were low risk based on sPESI scores. CONCLUSION: Admission rates for DVT and PE have remained high and unchanged, especially with PE, minorities, and in older patients. Based on sPESI scores, up to half of PE patients might be eligible for early discharge or outpatient therapy.
Adult ; Anticoagulants ; Continental Population Groups ; Diagnosis ; Embolism ; Emergencies* ; Emergency Service, Hospital* ; Female ; Hispanic Americans ; Humans ; Outpatients ; Pulmonary Embolism* ; Venous Thromboembolism* ; Venous Thrombosis

OBJECTIVE: Disturbances in potassium (K) levels are relatively common and may be associated with significant morbidity and mortality; however, treatments vary. Our purpose was to determine the incidence, treatments, and outcomes associated with hyperkalemia and hypokalemia in emergency department (ED) patients. METHODS: We performed a structured, retrospective review of electronic medical records of consecutive adult ED patients with K measured while in the ED. Demographic, clinical, and laboratory data as well as treatments, disposition, and in-hospital complications were collected. Univariate and multivariate analyses, presented as adjusted odds ratios, were used to compare outcomes by K levels. RESULTS: Of 100,260 visits in 2014, an ED K level was ordered in 48,827 (49%). A total of 1,738 patients (3.6%) were excluded because of sample hemolysis. The K was low (<3.5 mEq/L) in 5.5%, normal (3.5 to 5.0 mEq/L) in 90.9%, and elevated (>5.0 mEq/L) in 3.6% of patients. Patients with hyperkalemia were older (64 vs. 49 years, P<0.001) and more likely male (58% vs. 40%, P<0.001). Treatment for hyperkalemia varied greatly. After adjusting for confounders, both hyperkalemia and hypokalemia were associated with inpatient hospitalization and death. At least one medication was used to manage hyperkalemia in 11.5% of patients with a K of 5.1 to 5.4 mEq/L, 36.4% of those with a K 5.5 to 6 mEq/L and 77.0% of the cohort with K >6 mEq/L. CONCLUSION: Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.
Adult ; Cohort Studies ; Electronic Health Records ; Emergencies* ; Emergency Service, Hospital* ; Hemolysis ; Hospitalization ; Humans ; Hyperkalemia ; Hypokalemia ; Incidence ; Inpatients ; Male ; Mortality ; Multivariate Analysis ; Odds Ratio ; Potassium* ; Retrospective Studies*

Objective: To our knowledge, this is the first comprehensive study using a nationally representative database to estimate the frequency of critical procedures (endotracheal tube intubation [ETI], cardiopulmonary resuscitation [CPR], and central line insertion [CLI]) in children and adults. Methods: The study was based on the secondary analysis of the 2010-2014 National Hospital Ambulatory Medical Care Survey. We included adult and pediatric patients undergoing critical procedures in the emergency department. We extracted demographic and clinical information, including the performance of critical procedures. For frequent procedures (≥1 per year), we estimated the annual number of critical procedures per emergency physician (EP) by dividing the total number of annual critical procedures by the total number of EPs (estimated at 40,000). For infrequent procedures, we calculated the average interval between procedures. We summarized the data with descriptive statistics and 95% confidence intervals (CIs). Results: There were an estimated 668 million total emergency department visits (24% pediatric). On average, a single EP performed 8.6 (95% CI, 5.5 to 11.7) CLIs, 3.7 (95% CI, 2.4 to 5.0) CPRs, and 6.3 (95% CI, 5.3 to 7.4) ETIs per year in adults. In comparison, a single EP performed one pediatric CLI, CPR, and ETI every 3.2 (95% CI, 1.9 to 9.8), 5.2 (95% CI, 2.8 to 33.5), and 2.8 (95% CI, 1.6 to 8.9) years, respectively. Conclusion Our nationwide findings confirm those of previous smaller studies that critical procedures are significantly fewer in children than adults. We suggest that methods to retain skills in pediatric critical procedures should be developed for general EPs to ensure that they deliver the highest level of care across the entire age spectrum.