J Emerg Med
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The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. ⋯ Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.
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Delayed presentation of orbital trauma as an acute subperiosteal hematoma. ⋯ A 12-year-boy developed sudden painful abaxial proptosis of the left eyeball 15 days after blunt trauma over the forehead. On contrast-enhanced computed tomography, a heterogeneous, hypodense, non-enhancing mass with biconvex contour was seen adjacent to the orbital roof. Direct needle drainage was performed and about 10 mL dark blood was aspirated. Proptosis reduced immediately and resolved completely at 2 weeks follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Sudden proptosis with no immediate history of trauma can be alarming for the emergency physician. Familiarity with this clinical entity and early drainage can decrease morbidity.
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Emergency medicine (EM) residency programs use nonstandardized criteria to create applicant rank lists. One implicit assumption is that predictive associations exist between an applicant's rank and their future performance as a resident. To date, these associations have not been sufficiently demonstrated. ⋯ Our study found only weak correlations between GR and AR, UR, and IR, suggesting that those variables may not be strong predictors of resident performance. This has important implications for EM programs considering the resources devoted to applicant evaluation and ranking.
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Single-use plastic blades (SUPB) and single-use metal blades (SUMB) for direct laryngoscopy and tracheal intubation have not yet been compared with reusable metal blades (RUMB) in difficult airway scenarios. ⋯ Generally, results are in line with previous studies showing significant disadvantages of SUPB in both manikin scenarios. Therefore, metal blades might be beneficial, especially in the airway management of patients with inhalation injury.
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Epistaxis is a common emergency department (ED) complaint; however, this entity is rare among children younger than 2 years of age. In this age group, epistaxis may be a presenting sign of a bleeding disorder or nonaccidental trauma. ⋯ We present a case of a 2-month-old infant who was evaluated in the pediatric ED for epistaxis and discharged home. The infant returned 2 days later with facial swelling and irritability, and was found to have significant head trauma. In this article we review the epidemiology and differential diagnoses for epistaxis among infants, as well as the initial approach to the evaluation of this uncommon clinical entity in this age group. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Potential etiologies for epistaxis among infants and young children include severe systemic disease and nonaccidental trauma. Given its rarity and possible clinical significance, the approach to epistaxis differs in this age group. Emergency physicians should screen for and exclude a bleeding disorder while also having a very low threshold for a nonaccidental trauma evaluation.