Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Penetrating Extremity Trauma (PET) may result in arterial injury, a rare but limb- and life-threatening surgical emergency. Timely, accurate diagnosis is essential for potential intervention in order to prevent significant morbidity. ⋯ In PET patients, positive US may obviate CTA. In patients with a normal examination (no hard or soft signs) and a normal ABI, arterial injury can be ruled out. However, a normal ABI or negative US cannot independently exclude arterial injury. Due to high study heterogeneity, we cannot make recommendations when hard signs are present or absent or when ABI is abnormal. In these situations, one should use clinical judgment to determine the need for further observation, CTA or catheter angiography, or surgical exploration.
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Review Meta Analysis
Intravenous versus Non-Intravenous Benzodiazepines for the Abortion of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
The acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity. ⋯ Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted.
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Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. ⋯ Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA.
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Review Meta Analysis
Prioritizing systemic corticosteroid treatments to mitigate relapse in adults with acute asthma. A systematic review and network meta-analysis.
While systemic corticosteroids (SCS) are widely used to prevent relapse in adults with acute asthma discharged from the emergency department, the most effective route of administration is unclear. The objective of this review was to examine the effectiveness of SCS in adults and to identify the most effective route of SCS to preventing relapse. ⋯ The network analysis identified IM corticosteroids and PO long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to PO short-course corticosteroids. The lack of significant findings with PO short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer PO SCS treatment options in adults.
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Review Meta Analysis
Predictors of Airspace Disease on Chest X-Ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis.
An abnormal chest X-ray (CXR) inconsistent with simple bronchiolitis is found in 7%-23% of cases. Despite national guidelines stating "current evidence does not support routine radiography in children with bronchiolitis"; the use of CXR in these patients remains high. Inappropriate use of CXR not only exposes children to excess radiation, but also increases medical costs. The majority of the time, CXRs are obtained to diagnose or rule out pneumonia. We aim to provide an evidence-based approach defining the utility of CXR in bronchiolitis for the diagnosis and treatment of bacterial pneumonia. ⋯ No single predictor of a +CXR was of sufficient accuracy to either support or refute ordering a CXR in a child with clinical bronchiolitis. We provide a decision threshold model to estimate a test threshold for obtaining a CXR and a treatment threshold for administering antibiotics. Application of this model requires the clinician to approximate the empiric benefit of antibiotics based on the clinical situation, highlighting the importance of clinical assessment.