J Emerg Med
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Randomized Controlled Trial
A Randomized Controlled Trial of a Single Dose Furosemide to Improve Respiratory Distress in Moderate to Severe Bronchiolitis.
Bronchiolitis is one of the most common disorders of the lower respiratory tract in infants. While historically diuretics have been used in severe bronchiolitis, no studies have looked directly at their early use in children in the emergency department. ⋯ While theoretically a single dose of a diuretic to reduce lung fluid would improve respiratory distress in children with bronchiolitis, our randomized controlled medication trial showed no difference in outcomes. ClinicalTrials.gov ID: NCT02469597.
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Emergency surgical amputations are rare and resource-intensive lifesaving interventions. Most emergency medical services (EMS) lack a formal protocol to manage these high-risk but low-occurrence events. There has been limited attention in the EMS community to address this issue. Without a literature-based approach, the EMS community has been offered little guidance on managing surgical field amputations. ⋯ A 38-year-old man was terminally entrapped below the waist in an industrial auger. As a last resort, the decision to initiate a field amputation was made. We outline an adaptive strategy to address the circumstances surrounding this entrapment scenario. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A carefully preplanned protocol may lead to increased overall survivability for entrapped patients requiring emergent field amputation. Based on the lessons learned from the outcome of this case, previous cases, and a literature review, we have devised a simplified planning tool in the form of a "LIMB" mnemonic to aid EMS services in developing their own traumatic amputation protocol (TAP). "LIMB" is an acronym for: Lists of resources and equipment, Initiate TAP checklist, Manage the extrication, and Bring the patient in. The LIMB mnemonic may also be used as a checklist to assist EMS personnel in performing a field amputation. We offer rescuers a starting point to develop their own TAP capable of being executed in their own rescue environment.
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Hemangiomas are common cutaneous findings on healthy infants. These vascular malformations are generally benign, though in rare circumstances they can potentially be fatal. This is particularly true when the hemangiomas are large or numerous and occurring in visceral organs. Previously unrecognized visceral hemangiomas are part of the differential for any neonate presenting unexpectedly in shock. ⋯ A 10-day-old neonate presented to the pediatric emergency department with difficulty breathing. On examination, he appeared to be in respiratory distress and in shock. Echocardiography showed cardiomegaly, and an abdominal ultrasound showed a massive and heterogeneous liver. Magnetic resonance imagine performed after stabilization in the pediatric intensive care unit verified the presence of diffuse infantile hepatic hemangiomas. This case demonstrates how numerous visceral hemangiomas can generate high-volume vascular steal, distributive shock, and cardiac failure. Our patient was subsequently noted to have bruits over his liver. WHY AN EMERGENCY PHYSICIAN SHOULD BE AWARE OF THIS?: Diffuse hemangiomas and arteriovenous malformations are rare causes of extrinsic cardiogenic shock in the neonate. Targeted palpation of an enlarged liver or auscultation of a right upper quadrant bruit can raise suspicion of this diagnosis.
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Out-of-hospital cardiac arrest has high rates of morbidity and mortality, and a growing body of evidence is redefining our approach to the resuscitation of these high-risk patients. ⋯ TFCPR has been associated with improved patient outcomes in the prehospital setting. The data are less compelling for other commonly used advanced resuscitation tools and procedures. Emergency physicians should consider incorporating the TFCPR approach into ED cardiac arrest resuscitation to optimize delivery of those interventions most associated with improved outcomes.
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Infection is the second leading cause of death in end-stage renal disease (ESRD) patients. Prior investigations of acute septic shock in this specific population are limited. ⋯ ESRD patients comprise a small but important portion of patients with ED septic shock. Although presentation clinical profiles are similar to patients without ESRD, ESRD status is independently associated with lower fluid dose and compliance with the 30-mL/kg fluid goal. Hyperlactatemia is a marker of mortality in ESRD septic shock.