In 261 ED patients over age 65 receiving first generation antihistamines, 15% had an adverse reaction. Most common was delirium and urinary retention. Age over 85, previous cognitive impairment and multiple doses increased the risk of adverse reaction. Along with previous literature, this should discourage use of first generation antihistamines in older ED patients.
In this study reviewing data from the American College of Emergency Physicians’ Emergency Quality Network substance use disorder program, EDs prescribed naloxone in 27% of patients discharged after opioid overdose. Only 7% received ED administered or prescription for buprenorphine, etc. There is a lot of room for improvement in the care we provide for this subset of ED patients.
Much has been written about the benefits of prehospital blood transfusion for traumatic hemorrhage. Can this success be ascribed to non-traumatic hemorrhage as well? This small study (50 patients over 10 years!) says there were improvements in patient physiology (shock index) for those patients receiving blood for GI bleed, etc. Much more research is needed however this could be a beneficial practice in the future.
This systematic review found improved pain scale at 15 and 120 minutes in 495 patients who received nebulized ketamine. Dosing at 0.75 mg/kg was as effective as 1.5 mg/kg and the nebulized ketamine was non-inferior to IV morphine and ketamine with fewer side effects.
The Geriatric Measurement Tool (GMT) was used in this study prospectively to assess 24 hour mortality rate in ED patients over age 65. The GMT is a combination of FRAIL Questionnaire and Barthel index for Activity of Daily Living. The study found:
“ From 700 enrolled patients, GMT categorization revealed that 53.6% of patients were in Category-4 (moderate/more dependent and frail), while 34% were in Category-1 (independent or slight dependency, prefrail/fit). The 24-h mortality rate was 9%. GMT Category-4 demonstrated high sensitivity (87.3%) for mortality prediction, but low specificity (49.7%). Conversely, GMT Category-1 showed low sensitivity (44.1%) but high specificity (90.2%) for predicting discharge.”
Probably the biggest take away is we should be thinking about assessing our older patient's health status using some validated scale/tool to help us have conversations with patients and families regarding prognosis and interventions.
The Geriatric Measurement Tool combines the FRAIL Questionnaire with the Barthel Index For Daily Living to give a prognosis on your patient's mortality. First used to predict mortality in older patients with pneumonia during COVID-19 pandemic. Now being investigated for other ED patient populations.
FRAIL Questionnaire: Fatigue, Resistance, Aerobic, Illness, Weight loss. https://www.activeagingweek.com/pdf/abbott/FRAILQuestionnaire.pdf
Barthel: Ten questions about ADL's to create a score 0-100. https://www.mdcalc.com/calc/3912/barthel-index-activities-daily-living-adl
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.
