This study looked at industry sponsored payments to EM physician through non-covered entities (ie not directly to physician or through an academic institution). It found a $100 million increase from 2015-23 in this payment model. It appears that private equity is not the only money entering emergency medicine in the past decade.
Total value of Industry-Sponsored Research Payments (ISRPs) by company. The 20 companies with highest total ISRPs awarded to emergency physician PIs.
We have all been on that busy shift and just quickly looked at the impression section of the radiology report whether that is a CT, plain film, US or MRI. In doing this you run the risk of missing important information that is contained in the body of the report and has either not been carried down into the impression or contradicts the impression by some error.
To avoid missing important information that can impact patient care, always read the entire report and look at the images yourself. You have seen the patient, know the clinical history, and a second set of eyes never hurts.
Previous small studies had put the prevalence of hypocalcemia in trauma patients at 23-56%. This single center study of 2200 patients looked at prevalence and outcome and found a much lower prevalence however worse outcomes than those who were not hypocalcemic.
This study is a reminder of the efficacy of regional nerve blocks for older patient's with hip fractures. The authors trained EM physicians for 2 hours then evaluated delirium levels in patients who did and did not receive nerve blocks for hip fractures.
This study demonstrated that administration of prehospital blood to trauma patients lead to a higher rate of survival in patients whose initial ED vital signs or pre-hospital shock index would have predicted death.
This review article reminds us that circulation needs to be prioritized over airway in trauma patients. This means bleeding control (pressure on wound, tourniquet, surgery/IR intervention), correcting tension pneumothorax, correcting pericardial tamponade, as well as resuscitation to return physiologic homeostasis (blood products, vasopressors where needed, warm the patient, etc.) before intubation. Altered mental status/low GCS may be due more to hypoperfusion than neurologic injury. Correcting the hypotension may alleviate that need to intubate.
Intraabdominal infections leading to sepsis can come from cholecystitis, small bowel perforation, gastric perforation, left sided colonic diverticulitis, right sided diverticulitis and appendicitis. When to initiate source control and antibiotics is controversial. These authors propose breaking patient populations into three groups:
From this they propose algorithms to treat these intraabdominal infections such as (note the different approach to right and left diverticulitis):
This article looks at source control as it relates to intrabdominal sources for sepsis. Key take aways are:
Those at high risk of morbidity and mortality from intraabdominal infection associated sepsis include:
Mild–moderate immune deficiency: Elderly (according to the age and general status of the patient), Malnourished, Diabetic, Burns, Trauma, Uremic, Active malignancy, not on chemotherapy, HIV with CD4+ count >200/mm3, Splenectomized, Severe immune deficiencyAIDS HIV with CD4+ count <200/mm3, Transplant (solid organ, bone marrow), High-dose steroids (more than 20 mg/day prednisone), Malignancy on chemotherapy, Neutrophil count <1,000/mm3
High-risk population (medical or surgical causes)Low serum albumin concentration Older age Obesity Smoking Diabetes mellitus Ischemia secondary to vascular disease or irradiation Prolonged or delayed/late procedures
Comparing prescribing patterns from early 2000s to late 2010s in the National Hospital Ambulatory Medical Care Survey, these authors found we continue to under prescribe pain medications to non-white patients for traumatic injuries.
A prospective cohort of South Korean patients over 65 years admitted from the ED with critical illness had Clinical Frailty Scale (CFS) performed on them. Those with a high CFS had increased 3 month mortality. CFS helps us prognosticate morbidity and mortality in our older critically ill patients.
In 252 mild traumatic brain injury patients seen at 3 level I centers that were given the Rivermead Post Concussion Symptoms Questionnaire within 24 hours of arrival, 3 month post concussive symptoms were significantly correlated with their score on the questionnaire. This questionnaire take 3 minutes to complete. This may be helpful in prognosticating who will have post-concussive symptoms and who will need additional follow up.
In reviewing the limited literature available, the authors found that fascia iliaca blocks did not improve mortality but did improve hospital length of stay, decreased opiate use, and decreased delirium rates. More research is needed, however this tool should be added to our multimodal pain control toolbox.
This group looked at 88 patients intubated for penetrating neck injury and found 95% received neuromuscular blocking agents, 73% were intubated using a bougie, and 95% were intubated on first pass.
The authors concluded; “Rapid sequence intubation with bougie use was an effective default approach to definitive airway management in ED patients with penetrating neck trauma.”
These authors followed 250 consecutive trauma activation patients over a one year period. In hospital elevated blood pressure and glucose level correlated with a new diagnosis of hypertension and diabetes respectively over that 1 year time line. Some of these patients also had a new diagnosis of HIV, substance use disorder and hepatitis C. Using their contact with the health system due to trauma can be a way to screen for undiagnosed medical problems such as diabetes and hypertension. Assuring outpatient follow up for these patients will have an effect on their long term morbidity and mortality.
In a German study comparing one EMS jurisdiction which used IV paracetamol (acetaminophen) in combination with nalbuphine (Nubian, opiate agonist/antagonist) to another jurisdiction which used piritramide (synthetic opioid similar to fentanyl) for prehospital traumatic pain, the combination worked better to decrease pain on a numerical scale. There were no differences in typical safety measures.
The use of an antagonist/agonist theoretically could precipitate withdrawal in non-opiate naive patients and could influence in hospital analgesic choices. The literature on this is mixed.
This study offers further evidence of the efficacy of multi-modal pain control, the feasibility of paramedics using IV paracetamol and the possibility of using rapid onset opioid agonist/antagonist in the prehospital setting.
A scoping review of literature involving norepinephrine use during cardiac arrest associated with a shockable rhythm found:
-evidence in animal and signal in human trials of improved myocardial and cerebral blood flow
-a suggestion of less re-arrest
There is not enough evidence comparing epinephrine to norepinephrine however this would be an excellent area of research with a theoretical advantage to norepinephrine.
In the newly released American Heart Association guidelines on CPR and cardiovascular care, they state there is no evidence that mechanical compression devices show improvement in survival when compared to manual CPR. They do not recommend routine use of mechanical devices except when high quality CPR can not be maintained or when healthcare personnel safety is impacted such as during transport to the hospital.
Surely there will be more to follow on this topic.
These authors looked at survival to discharge pre and post-implementation of a single dose epinephrine protocol for out of hospital cardiac arrest as it relates to age ranges. They found that older patients had a survival rate of 12% in the single dose protocol compared to 6% in the multidose protocol. Younger and middle aged patients had no difference in survival pre and post-implementation. At least in older adults, epinephrine does not seem to offer much benefit when given more than one time during cardiac arrest.
The authors conducted a pre- and post-implementation study after five North Carolina county EMS agencies switched to single dose epinephrine during out of hospital cardiac arrest treatment from the traditional multidose (every 3-5 minutes) protocol. They looked at 1 year before and 1 year after implementation. They found no difference in survival to discharge from the hospital in the two groups but there was less return to spontaneous circulation in the single dose group.
Another paper emphasizing care for brain injured patients should include:
-pre-intubation preoxygenation to avoid hypoxia
-pre-intubation avoid extremes in blood pressure (hypotension kills)
-use hemodynamically neutral induction agents such as ketamine or etomidate
-post intubation target eucapnia on the ventilator. (do not aim for low CO2)
-post intubation maintain adequate sedation to avoid increased intercranial pressure
