Annals of emergency medicine
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Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination. ⋯ In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.
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Case Reports
Unintentional Pediatric Ingestion of Electronic Cigarette Nicotine Refill Liquid Necessitating Intubation.
Liquid nicotine used in electronic cigarette devices is highly concentrated, unreliably packaged, and poorly regulated. We present a case report of a 6-year-old female who developed severe toxicity and required intubation after an unintentional oral ingestion of approximately 703 mg (35 mg/kg) of liquid nicotine, with accompanying serum and urine concentrations of nicotine and its metabolites. Analysis of the ingested liquid suggests a nicotine concentration of 140.6 mg/mL in the purchased commercial product, or 234% of its labeled concentration. Clinicians should be aware of these products and the potential severity of toxicity they may incur.
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Among children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital. ⋯ Children without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.
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Some patients are agitated and unable to tolerate conventional preoxygenation methods, including face mask oxygen or noninvasive positive-pressure ventilation. Sedation with ketamine for preoxygenation, also known as delayed sequence intubation, is a technique that can be used to achieve preoxygenation in this patient population. No complications of delayed sequence intubation have previously been reported. ⋯ She had no respiratory effort between the onset of apnea and pharmacologic paralysis. Apnea can occur in critically ill patients who receive ketamine to facilitate preoxygenation. Sedation remains a valuable technique to enable optimal preoxygenation in agitated patients; however, clinicians should not perform this technique lightly and should be prepared to secure the patient's airway immediately.