The American journal of emergency medicine
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Multicenter Study
Factors influencing secondary overtriage in trauma patients undergoing interhospital transfer: A 10-year multi-center study in Hong Kong.
With the development of regionalised trauma networks, interhospital transfer of trauma patients is an inevitable component of the trauma system. However, unnecessary transfer is a common phenomenon, and it is not without risk and cost. A better understanding of secondary overtriage would enable emergency physicians to make better decisions about trauma transfers and allow guidelines to be developed to support this decision making. This study aimed to describe the pattern of secondary overtriage in Hong Kong and identify its associated factors. ⋯ Interhospital transfer is an essential component of the trauma system. However, over one-fifth of the transfers were considered unnecessary in Hong Kong, and this could be considered to be an inefficient use of resources as well as cause inconvenience to patients and their families. We have identified related factors including blunt trauma, AIS <3 scores for head or neck, thorax, abdomen and extremities, and opportunities to establish and improve on transfer protocols. Further research should be aimed to safely reduce interhospital transfers in the future to improve the efficiency of the Hong Kong trauma system.
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Case Reports
Severe caffeine poisoning with mexiletine successfully treated by extracorporeal methods: A case report.
A 20-year-old woman was brought to the hospital in an ambulance after ingesting 18 g of caffeine and 3500 mg of mexiletine 80 min earlier. On arrival at the emergency department, her vital signs were as follows: blood pressure, 65/37 mmHg; heart rate, 140 beats/min; and Glasgow Coma Scale, E4V4M6. Laboratory analyses revealed hypokalemia and lactic acidosis. ⋯ In this case, the endogenous clearance of caffeine, calculated from blood concentrations, was considerably lower than estimated. If HD had not been performed, it may have taken longer to wean off the VA-ECMO because of reduced caffeine clearance in the presence of mexiletine. Notably, caffeine poisoning is more severe and prolonged when mexiletine is administered.
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According to the guidelines of the American Heart Association and American College of Emergency Physicians, respectively, there is no indication for immediate lowering of asymptomatic hypertension in the Emergency Department (ED), and no requirement for routine diagnostic testing in these patients. Despite this, asymptomatic hypertension represents a recurring source of referrals for ED evaluation from other healthcare settings, or from patient self-referral, with significant practice variation in the evaluation and treatment of this complaint. ⋯ Our findings redemonstrate that patients presenting to the ED with asymptomatic hypertension are at low risk for short-term complications of hypertension, and that diagnostic testing is low yield in this population. While we were able to achieve reductions in unnecessary testing, further work is needed to educate clinicians and improve adherence to evidence based principles when caring for these patients.