Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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Randomized Controlled Trial Comparative Study
Emergency cricothyroidotomy: a randomized crossover trial comparing percutaneous techniques: classic needle first versus "incision first".
Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an "incision-first" modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method. ⋯ The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy.
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The objectives of this study were to determine, in patients admitted to the hospital from the emergency department (ED) without evidence of trauma, 1) the prevalence of clinically important abnormalities on cranial computed tomography (CCT) and 2) the frequency of emergent therapeutic interventions required because of these abnormalities. ⋯ Of patients without evidence of trauma who receive CCT in the ED, the prevalence of focal neurologic findings and clinically important abnormalities on tomography is low, the need for emergent intervention is very low, and the large majority of patients requiring emergent intervention have focal findings. The yield of CCT was lower for patients presenting with AMS, and higher for patients presenting with motor weakness or speech abnormalities, and for those who were unresponsive.
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Review Case Reports
A model for emergency department end-of-life communications after acute devastating events--part I: decision-making capacity, surrogates, and advance directives.
Making decisions for a patient affected by sudden devastating illness or injury traumatizes a patient's family and loved ones. Even in the absence of an emergency, surrogates making end-of-life treatment decisions may experience negative emotional effects. Helping surrogates with these end-of-life decisions under emergent conditions requires the emergency physician (EP) to be clear, making medical recommendations with sensitivity. ⋯ EPs should also help the surrogate and family understand that palliative care addresses comfort needs of the patient including adequate treatment for pain, dyspnea, or anxiety. Part I of this communications model reviews determination of decision-making capacity, surrogacy laws, and advance directives, including legal definitions and application of these steps; Part II (which will appear in a future issue of AEM) covers communication moving from resuscitative to end-of-life and palliative treatment. EPs should recognize acute devastating illness or injuries, when appropriate, as opportunities to initiate end-of-life discussions and to implement shared decisions.
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Randomized Controlled Trial Multicenter Study Comparative Study
Observational study of telephone consults by stroke experts supporting community tissue plasminogen activator delivery.
Barriers to intravenous (IV) tissue plasminogen activator (tPA) use in ischemic stroke include limited treatment experience of community physicians. Models of acute stroke care have been designed to address these limitations by providing community support. These include support by telephone or televideo, with or without subsequent transport to tertiary care centers. The authors describe the frequency, characteristics, and effect of community phone consultations to a 24/7 stroke "hotline" staffed by stroke physicians at an academic stroke center using such a model. ⋯ Providing tPA decision-making support via telephone consult to community physicians is feasible and safe. Consultants may play a more prominent role in determining tPA ineligibility than acceptance. Future work should include a real-time survey of physician providers to ascertain such potential qualitative benefits of a stroke hotline.
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The authors previously derived a clinical decision rule (CDR) for chest radiography in patients with chest pain and possible acute coronary syndrome (ACS) consisting of the absence of three predictors: history of congestive heart failure, history of smoking, and abnormalities on lung auscultation. The aim of the investigation was to prospectively validate and refine the CDR for chest radiography in an independent patient population. ⋯ Prospective validation of our previously derived CDR for clinically important chest radiographic abnormalities was not successful. Derivation of a refined rule identified all clinically important radiographic abnormalities, but was insufficiently specific. No CDR with adequate sensitivity and specificity could be found.