The American journal of emergency medicine
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Randomized Controlled Trial Clinical Trial
Screening with blood urea nitrogen before intravenous contrast.
In some settings, blood urea nitrogen (BUN) values are available well in advance of creatinine values. We wanted to determine whether BUN values can be used to screen for renal insufficiency for the purpose of intravenous contrast administration. From laboratory records, we derived and validated cutpoints for BUN values to detect creatinine values >/=2.0 mg/dL. "Sensitive" and "high-yield" cutpoints were derived using records from 5000 consecutive patients and validated using a random set of 2000 patients. ⋯ BUN >/=20 mg/dL, the "high-yield cutpoint," had sensitivity of 0.98 (95% CI, 0.95-0.99) and specificity of 0.71 (95% CI, 0.69-0.73). Negative likelihood ratios for these cutpoints were 0.005 and 0.03, respectively. BUN values <15-20 mg/dL provide strong evidence against renal insufficiency.
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Using a retrospective chart review, we compared the use of chest radiography (CXR) and arterial blood gas testing (ABG) before (pre-P) and after (post-P) initiation of specific ordering guidelines for the use of these studies for patients presenting to the ED with acute asthma exacerbation. We noted the number of tests performed, the indication for the test, and the results when performed. There was a 55% reduction in the number of chest radiographs (85 of 213 patients pre-P had CXR as compared with 40 of 222 patients post-P, P <.001). ⋯ There was a 57% reduction in the number of arterial blood gases post-P (9 of 222 patients) as compared with pre-P (20 of 213 patients, P <.001). Although patients with abnormal ABGs had a discernible indication for testing, all of the ABGs for which no indication could be found were normal. A protocol containing criteria for obtaining chest x-rays and arterial blood gas testing can reduce the use of diagnostic testing, thereby improving ED efficiency without adversely impacting patient care.
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Hypokalemia with paralysis (HP) is a potentially reversible medical emergency. It is primarily the result of either hypokalemic periodic paralysis (HPP) caused by an enhanced shift of potassium (K(+)) into cells or non-HPP resulting from excessive K(+) loss. Failure to make a distinction between HPP and non-HPP could lead to improper management. ⋯ A very low rate of K(+) excretion coupled with the absence of a metabolic acid-base disorder suggests HPP, whereas a high rate of K(+) excretion accompanied by either metabolic alkalosis or metabolic acidosis favors non-HPP. The therapy of HPP requires only small doses of potassium chloride (KCl) to avoid rebound hyperkalemia. In contrast, higher doses of KCl should be administered to replete the large K(+) deficiency in non-HPP.
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Case Reports
Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED.
This report describes usefulness of magnetic resonance imaging (MRI) for the evaluation of the patient suspected of Wernicke encephalopathy (WE). Magnetic resonance imaging shows characteristic findings of symmetric hyperintense lesions predominantly located in the bilateral medial thalami, the periaqueductal regions, and the mamillary bodies. The diagnosis of Wernicke encephalopathy has been based generally on history and clinical symptoms. We now believe that MRI could be used as a diagnostic adjunct in the patient suspected of WE.
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A successful ED relies on its leaders to master and demonstrate core competencies to be effective in the many arenas in which they interact and are responsible. A unique matrix model for the assessment of an ED leadership's key administrative skill sets is presented. ⋯ This dynamic tool has provided a unique perspective for the evaluation and enhancement of overall ED leadership performance. It is hoped that incorporation of such a model will similarly improve the accomplishments of EDs at other institutions.