Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
-
Observational Study
Short term prognosis and current management of syncopal patients at intermediate-risk. Results from the IRiS (Intermediate-Risk Syncope) Study.
Despite guidelines, admission rates and expenditures for syncope remain high. This may be caused by an imprecise definition of cardiovascular disease considered at risk and an overestimation of the role of comorbidities and advanced age. In a cohort of patients with undetermined syncope, we prospectively compared the short-term prognosis of patients at intermediate risk (i.e., with stable heart diseases or comorbidities, of any age) versus those at high risk for cardiogenic syncope and identified factors associated with serious events. Secondarily, we analyzed the current management of intermediate-risk patients. ⋯ According to the results of this study, the authors believe that intermediate-risk patients could be safely discharged, with potentially significant costs saving. In prognostic stratification, priority is to seek risk factors for cardiogenic syncope while advanced age, stable heart diseases, or comorbidities likely lead to inappropriate hospitalization.
-
Review Meta Analysis
Near-infrared spectroscopy monitoring during cardiac arrest: a systematic review and meta-analysis.
Tissue oximetry using near-infrared spectroscopy (NIRS) is a noninvasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest (CA) because of its ability to give measures in low-blood-flow situations. The aim of this study was to assess the evidence regarding the association between the types of NIRS measurements (mean, initial, and highest values) and resuscitation outcomes (return of spontaneous circulation [ROSC], survival to discharge, and good neurologic outcome) in patients undergoing cardiopulmonary resuscitation. ⋯ Patients with good resuscitation outcomes have significantly higher NIRS saturations during resuscitation than their counterparts. The types of NIRS measurements during resuscitation influenced the association between ROSC and NIRS saturation. Prolonged failure to obtain a NIRS saturation higher than 30% may be included in a multimodal approach to the decision of terminating resuscitation efforts (Class IIb, Level of Evidence C-Limited Data).
-
Randomized Controlled Trial
Double-blind randomized controlled trial of intranasal dexmedetomidine versus intranasal midazolam as anxiolysis prior to pediatric laceration repair in the emergency department.
The objective of this study was to compare anxiolysis with intranasal dexmedetomidine, an alpha-2 agonist, versus intranasal midazolam for pediatric laceration repairs. ⋯ Intranasal dexmedetomidine is an alternative anxiolytic medication to intranasal midazolam for pediatric laceration repairs, performing similarly in our study, except that patients who received dexmedetomidine had less anxiety at the time of positioning for procedure.
-
Observational Study
Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria.
The use of chest computed tomography (CT) to evaluate emergency department patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified "low risk." We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients. ⋯ We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria-chest CT may be indicated in cases requiring greater anatomic detail and injury characterization.
-
Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. ⋯ To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.