Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children.

Abstract: First-aid guidelines recommend the administration of cool running water in the early management of thermal injury. Our objective is to analyze the associations between first aid and skin-grafting requirements […]

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ELDERLY ADULTS WITH ISOLATED HIP FRACTURES – ORTHOGERIATRIC CARE VERSUS STANDARD CARE: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.

Abstract: Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after […]

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Evaluation of infection rates with narrow versus broad-spectrum antibiotic regimens in civilian gunshot open-fracture injury.

Abstract: Civilian gunshot open-fracture injuries portray a significant health burden to patients. Use of antibiotics is endorsed by guideline recommendations for the prevention of post-traumatic infections, however, antimicrobial selection and […]

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Improving STEMI management in the emergency department: Examining the role of minority groups and sociodemographic characteristics.

Abstract: To evaluate whether a fast-track intervention program will reduce time-lags of patients with STEMI considering minority groups, various socioeconomic status (SES) and clinical risk factors.A retrospective-archive study was conducted […]

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Antimotility Agents For The Treatment Of Acute Non-Infectious Diarrhea In Critically Ill Patients: A Practice Management Guideline From The Eastern Association For The Surgery Of Trauma.

Acute non-infectious diarrhea is a common phenomenon in ICU patients. Multiple treatments are suggested but the most effective management is unknown. A working group of the Eastern Association for the Surgery of Trauma (EAST), aimed to evaluate the effectiveness of loperamide, diphenoxylate/atropine, and elemental diet on acute non-infectious diarrhea in critically ill adults and to develop recommendations applicable to daily clinical practice.The literature search identified 11 randomized controlled trials (RCT) appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to evaluate the effect of loperamide, diphenoxylate/atropine, and elemental diet on the resolution of non-infectious diarrhea in critically ill adults based on selected outcomes: improvement in clinical diarrhea, fecal frequency, time to the diarrhea resolution, and hospital length of stay.The level of evidence was assessed as very low. Analyses of 10 RCTs showed that loperamide facilitates resolution of diarrhea. Diphenoxylate/atropine was evaluated in three RCTs and was as effective as loperamide and more effective than placebo. No studies evaluating elemental diet as an intervention in patients with diarrhea were found.Loperamide and diphenoxylate/atropine are conditionally recommended to be used in critically ill patients with acute non-infectious diarrhea.Level IITherapeutic.

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Automatic proximal airway volume segmentation using optical coherence tomography for assessment of inhalation injury.

Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury with a mortality rate of up to 40%. Early management of ARDS has been difficult due to the lack of sensitive imaging tools and robust analysis software. We previously designed an optical coherence tomography (OCT) system to evaluate mucosa thickness (MT) after smoke inhalation, but the analysis relied on manual segmentation. The aim of this study is to assess in vivo proximal airway volume (PAV) after inhalation injury using automated OCT segmentation and correlate the PAV to lung function for rapid indication of ARDS.Anesthetized female Yorkshire pigs (n = 14) received smoke inhalation injury (SII) and 40% total body surface area thermal burns. Measurements of PaO2-to-FiO2 ratio (PFR), peak inspiratory pressure (PIP), dynamic compliance, airway resistance, and OCT bronchoscopy were performed at baseline, postinjury, 24 hours, 48 hours, 72 hours after injury. A tissue segmentation algorithm based on graph theory was used to reconstruct a three-dimensional (3D) model of lower respiratory tract and estimate PAV. Proximal airway volume was correlated with PFR, PIP, compliance, resistance, and MT measurement using a linear regression model.Proximal airway volume decreased after the SII: the group mean of proximal airway volume at baseline, postinjury, 24 hours, 48 hours, 72 hours were 20.86 cm (±1.39 cm), 17.61 cm (±0.99 cm), 14.83 cm (±1.20 cm), 14.88 cm (±1.21 cm), and 13.11 cm (±1.59 cm), respectively. The decrease in the PAV was more prominent in the animals that developed ARDS after 24 hours after the injury. PAV was significantly correlated with PIP (r = 0.48, p < 0.001), compliance (r = 0.55, p < 0.001), resistance (r = 0.35, p < 0.01), MT (r = 0.60, p < 0.001), and PFR (r = 0.34, p < 0.01).Optical coherence tomography is a useful tool to quantify changes in MT and PAV after SII and burns, which can be used as predictors of developing ARDS at an early stage.Prognostic, level III.

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Initiation of the ABCD3-I algorithm for expediated evaluation of transient ischemic attack patients in an emergency department.

The use of ABCD3-I score for Transient ischemic attack (TIA) evaluation has not been widely investigated in the ED. We aim to determine the performance and cost-effectiveness of an ABCD3-I based pathway for expedited evaluation of TIA patients in the ED.We conducted a single-center, pre- and post-intervention study among ED patients with possible TIA. Accrual occurred for seven months before (Oct. 2016-April 2017) and after (Oct. 2017-April 2018) implementing the ABCD3-I algorithm with a five-month wash-in period (May-Sept. 2017). Total ED length of stay (LOS), admissions to the hospital, healthcare cost, and 90-day ED returns with subsequent stroke were analyzed and compared.Pre-implementation and post-implementation cohorts included 143 and 118 patients respectively. A total of 132 (92%) patients were admitted to the hospital in the pre-implementation cohort in comparison to 28 (24%) patients admitted in the post-implementation cohort (p??0.05). The mean ABCD2 scores were 4.5 (1.4) in pre- and 4.1 (1.3) in post-implementation cohorts (p?=?0.01). The mean ABCD3-I scores were 4.5 (1.8) in post-implementation cohorts. Total ED LOS was 310?min (201, 420) in pre- and 275?min (222, 342) in post-implementation cohorts (p?>?0.05). Utilization of the ABCD3-I algorithm saved an average of over 40% of total healthcare cost per patient in the post-implementation cohort.The initiation of an ABCD3-I based pathway for TIA evaluation in the ED significantly decreased hospital admissions and cost with similar 90-day neurological outcomes.

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Short versus long axis ultrasound guided approach for internal jugular vein cannulations: A prospective randomized controlled trial.

Ultrasound-guided internal jugular vein cannulation is a standard procedure performed in ICUs worldwide. According to the guidelines, the short-axis approach is recommended over the long-axis approach for IJV cannulation. Double-operator cannulation is more convenient for the said procedure. However, the guidelines favor single-operator cannulation due to limited trials. We hypothesized that double-operator long-axis cannulation will be faster and have fewer complications than double-operator short-axis cannulation.This was a prospective, randomized trial of patients who needed central venous catheterization in the intensive care unit. The eligible patients were randomized into two groups. In one group, the short-axis view by two operators was used for cannulation, and the long-axis view by 2 operators was used in the other group. The time elapsed from skin puncture to guide-wire insertion.The central venous catheter was placed by ultrasound guidance in all 100 patients. No significant differences were observed in the patient characteristics between the two groups. The mean time of insertion was 74.2?±?110.1?s with the short-axis approach compared with 70.3?±?97.3?s with the long-axis approach. The frequency of complications was also significantly lower with the long-axis approach.The long-axis view for IJV cannulation has similar insertion and procedure timings to the short-axis view. However, the complication rate and number of needle punctures required were less with the long-axis view than with those with the short-axis view.

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Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries.

We describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription.A retrospective cohort study of Washington Medicaid beneficiaries was performed with linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the previous 12 months, and who filled a new opioid prescription within 1 day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use.Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months compared with 3.2% for patients who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills included a history of skeletal or connective-tissue disorder; neck, back, or dental pain; and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were observed among visits in which greater than or equal to 350 morphine milligram equivalents were prescribed. Conversion rates remained greater than 10% even among visits resulting in lower-dose opioid prescriptions.Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher-dose prescriptions are associated with increased risk for conversion; however, even visits that lead to guideline-concordant prescriptions bear some risk for long-term or high-risk use.

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The utility of a statewide prescription drug-monitoring database vs the Current Opioid Misuse Measure for identifying drug-aberrant behaviors in emergency department patients already on opioids.

The most recent guidelines on prescribing opioids from the United States Centers for Disease Control recommend that clinicians not prescribe opioids as first-line therapy for chronic non-cancer pain. If an opioid prescription is considered for a patient already on opioids, prescribers are encouraged to check the statewide prescription drug monitoring database (PDMP). Some additional guidelines recommend screening tools such as the Current Opioid Misuse Measure (COMM) which may also help identify drug-aberrant behaviors.To compare the PDMP and the Current Opioid Misuse Measure (COMM), a commonly-recommended screening tool for patients on opioids, in detecting drug-aberrant behaviors in patients already taking opioids at the time of ED presentation.Patients on opioids were enrolled prospectively in a mixed urban-suburban ED seeing approximately 65,000 patients per year. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratios of the PDMP and COMM were compared against objective criteria of drug-aberrant behaviors as documented in the electronic medical record (EMR) and medical examiner databases.Compared to the COMM, the PDMP had similar sensitivity (36% vs 45%) and similar specificity (79% vs 55%), but better positive predictive value, better negative predictive value, and better diagnostic odds ratio. The combination of the PDMP and the COMM did not improve the detection of drug-aberrant behaviors.The PDMP alone is a more useful as a screening instrument than either the COMM or the combination of the PDMP plus COMM in patients already taking opioids at time of ED presentation. However, the PDMP misses a majority of patients with documented drug-aberrant behaviors in the EMR, and should not be used in isolation to justify whether a particular opioid prescription is appropriate.

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Prehospital tranexamic acid shortens the interval to administration by half in Major Trauma Networks: a service evaluation.

Tranexamic acid (TXA) reduces bleeding and mortality. Recent trials have demonstrated improved survival with shorter intervals to TXA administration. The aims of this service evaluation were to assess the interval from injury to TXA administration and describe the characteristics of patients who received TXA pre-hospital and in-hospital.We reviewed Trauma and Audit Research Network records and local trauma registries to identify patients of any age that received TXA at all London Major Trauma Centres and Queen’s Medical Centre, Nottingham, during 2017. We used the 2016 NICE Guidelines (NG39) which state that TXA should be given within 3?hours of injury.We identified 1018 patients who received TXA, of whom 661 (65%) had sufficient data to assess the time from injury to TXA administration. The median interval was 74?min (IQR: 47-116). 92% of patients received TXA within 3?hours from injury, and 59% within 1?hour. Half of the patients (54%) received prehospital TXA. The median time to TXA administration when given prehospital was 51?min (IQR: 39-72), and 112?min (IQR: 84-160) if given in-hospital (p<0.001). In-hospital TXA patients had less haemodynamic derangement and lower base deficit on admission compared with patients given prehospital TXA.Prehospital administration of TXA is associated with a shorter interval from injury to drug delivery. Identifying a proportion of patients at risk of haemorrhage remains a challenge. However, further reinforcement is needed to empower pre-hospital clinicians to administer TXA to trauma patients without overt signs of shock.

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Valproic Acid Improves Survival and Decreases Resuscitation Requirements In a Swine Model of Prolonged Damage Control Resuscitation.

Although damage control resuscitation (DCR) is routinely performed for short durations, prolonged DCR may be required in military conflicts as a component of prolonged field care. Valproic acid (VPA) has been shown to have beneficial properties in lethal hemorrhage/trauma models. We sought to investigate whether the addition of a single dose of VPA to a 72-hour prolonged DCR protocol would improve clinical outcomes.Fifteen Yorkshire swine (40-45 kg) were subjected to lethal (50% estimated total blood volume) hemorrhagic shock (HS) and randomized to 3 groups: 1) HS; 2) HS-DCR; 3) HS-DCR-VPA (150 mg/kg over 3 hours) (n=5/cohort). In groups assigned to receive DCR, tactical combat casualty care (TCCC) guidelines were applied (1 hour into the shock period), targeting a systolic blood pressure (SBP) of 80 mm Hg. At 72 hours, surviving animals were given transfusion of packed red blood cells, simulating evacuation to higher echelons of care. Survival rates, physiologic parameters, resuscitative fluid requirements, and laboratory profiles were used to compare the clinical outcomes.This model was 100% lethal in the untreated animals. DCR improved survival to 20%, although this was not statistically significant. Addition of VPA to DCR significantly improved survival to 80% (p < 0.01). VPA-treated animals also had significantly (p < 0.05) higher SBPs, lower fluid resuscitation requirements, higher hemoglobin levels, and lower creatinine and potassium levels.VPA administration improves survival, decreases resuscitation requirements, and improves hemodynamic and laboratory parameters when added to prolonged DCR in a lethal hemorrhage model.None (pre-clinical study).

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