J Emerg Med
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In response to the opioid epidemic, our multidisciplinary team designed and integrated an alert-based, clinical-decision support intervention which identifies patients at risk of opioid misuse based on five evidence-based risk factors (early refill of opioids/benzodiazepines; >2 ED/Urgent Care visits with onsite opioids; >3 prescriptions of opioids/benzodiazepines; prior overdose; and positive toxicology screen). ⋯ Roughly 1 in 3 patients presenting to the emergency department for back pain received an opioid. A clinical decision support intervention to identify patients at risk of opioid use disorder had a minimal influence on opioid prescribing decisions in this population.
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Most mushroom exposures are benign and rare, with approximately 7400 yearly exposures. Of these, less than 1% of annual exposures can be attributed to cyclopeptide-containing mushrooms, amatoxins, and phallotoxins, with improved outcomes with early recognition. Notably, toxic ingestion of Amanita genus mushrooms is a rare but notable cause of acute liver failure. Approximately 95% of deaths worldwide associated with mushroom ingestion have been caused by amatoxin, the causative agent found in these mushrooms. ⋯ We present a case series involving eight family members, aged 8-44 years old, who shared a meal of these mushrooms foraged from the greater Northeast Philadelphia area. These individuals developed symptoms 8 hours postingestion and presented to the emergency department 16 hours postingestion. Three of them developed acute liver injury, and all recovered without the need for liver transplantation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases required a great deal of resources, including uncommonly utilized medications, active resuscitation, a thorough timeline investigation, and complex collaboration with pediatrics, toxicology, and a liver transplant-capable center. This community hospital involved logistical and supply challenges, including limited emergency department space, depletion of activated charcoal, and appropriate disposition despite relatively benign presentation.
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Definitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure. ⋯ By focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.
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Consensus is lacking regarding prehospital airway management in pediatric trauma patients (PTPs). ⋯ Prehospital B-APs were associated with shorter scene time and improvement in acuity compared with A-AP in PTPs. Variability in airway management practices across U.S. regions is high, leaving room for improvement in standardization of care and training.