The American journal of emergency medicine
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The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. ⋯ We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.
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Meta Analysis Comparative Study
Compression-only cardiopulmonary resuscitation vs standard cardiopulmonary resuscitation: an updated meta-analysis of observational studies.
Survival after compression-only CPR is comparable to standard CPR if the cause of arrest is cardiac.
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Geriatric problems frequently go undetected in older patients in emergency departments (EDs), thus increasing their risk of adverse outcomes. We evaluated a novel emergency geriatric screening (EGS) tool designed to detect geriatric problems. ⋯ The novel EGS is feasible, identifies previously undetected geriatric problems, and predicts determinants of subsequent care.
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Cranial computed tomography (CT) is generally regarded as the standard for evaluation of structural brain injury in patients with traumatic brain injury (TBI) presenting to the emergency department (ED). However, the subjective nature of the visual interpretations of CT scans and the qualitative nature of reporting may lead to poor interrater reliability. This is significant because CT positive scans include a continuum of structural injury with differences in treatment. ⋯ However, when interrater agreement was assessed with respect to the specific classification of the injury, agreement was poor, with a κ of 0.3 (0.29-0.316; confidence interval [CI] 95%). When classification was collapsed, considering only the presence or absence of hematomas, agreement among all 3 adjudicators improved to 55%, but the κ of 0.355, (0.332-0.78; CI 95%) was still only fair. The data suggest the need for improved recognition and quantification of specific structural injuries in the TBI population for better identification of patients requiring clinical intervention.
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The evidence for prognostication using lactate is often based on arterial lactate (AL). Arterial sampling is painful and difficult, and carries risks. Studies comparing peripheral venous lactate (PVL) with AL showed little difference but predominantly included patients with normal lactate. The objective of this study was to measure agreement between PVL and AL in patients with elevated venous lactate. ⋯ We report greater bias between VL and AL with broader LOA than previously documented. This may partly be due to the fact that we studied only patients with abnormal venous values, for whom close agreement would confer greatest clinical significance. The agreement between abnormal PVL and AL is poor and the high rate of misclassification may suggest that PVL is not a good substitute for AL if the venous lactate is abnormal.