Annals of emergency medicine
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Early diagnosis of appendicitis in infants and children can prevent perforation, abscess formation, and postoperative complications, and can decrease cost by shortening hospitalizations. This article reviews the epidemiology, physiology, and age-specific clinical presentation of childhood appendicitis. The accuracy of diagnostic adjuncts is reviewed, as are strategies for avoiding misdiagnosis and improving emergency department evaluation and management.
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The practice of emergency medicine routinely requires rapid decisionmaking regarding various interventions and therapies. Such decisions should be based on the expected risks and benefits to the patient, family, and society. At times, certain interventions and therapies may be considered "futile," or of low expected likelihood of benefit to the patient. ⋯ Physicians are under no ethical obligation to provide treatments they judge to have no realistic likelihood of benefit to the patient. Decisions to withhold treatment should be made with careful consideration of scientific evidence of likelihood of medical benefit, other benefits (including intangible benefits), potential risks of the proposed intervention, patient preferences, and family wishes. When certain interventions are withheld, special efforts should be made to maintain effective communication, comfort, support, and counseling for the patient, family, and friends.
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Chest pain centers in the emergency department have generally been accepted as a safe, cost-effective, and rapid approach to the evaluation, triage, and management of patients with potential acute coronary syndromes. These centers were initially designed to enhance patient care by decreasing time to treatment for acute myocardial infarction (AMI) and rapidly identifying patients with unstable angina. They also included community outreach and educational objectives designed to reduce time from the onset of chest pain to ED presentation. ⋯ New therapies for acute coronary syndromes make ED triage and risk stratification increasingly important. Although different chest pain center protocols have proved effective, all address the diagnosis and rapid treatment of acute myocardial necrosis, rest ischemia, and exercise-induced ischemia. Identifying patients with coronary artery disease in one of these stages in the spectrum of myocardial ischemia is the foundation for a successful chest pain center in the ED.
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Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. ⋯ Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk.