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Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions.This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 μg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05.Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group.Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

Background The most common presenting complaint to the emergency department (ED) is pain. Several studies have shown that a large proportion of ED patients either receive no or sub-optimal analgesia. Patient-controlled analgesia (PCA) pumps used in the post-operative setting has shown to decrease total opioid consumption and has increased patient and nurse satisfaction. Objective The purpose of this systematic review was to evaluate clinical trials that have used PCAs in the ED setting, to evaluate safety and efficacy as well as patient and healthcare provider experience. Methods A search of PubMed, MEDLINE, and the Cochrane Database was conducted using the MESH search terms emergency department, patient-controlled analgesia, and acute pain up to September 2021. These terms were searched in all fields of publication and were limited to the English-language articles, clinical “human” studies, and studies that included the use of patient-controlled analgesia in the setting of the emergency department. Results The search initially identified 227 potentially relevant articles and a total of 10 studies met criteria for inclusion. ED use of PCA therapy was associated with increased patient satisfaction, decreased pain scores, and an overall increase in opioid consumption. Conclusion The quality, the differences in study methods and outcome measures used, and heterogeneity of the studies performed to date do not provide adequate evidence to support its widespread use in the ED. Well-designed studies conducted in the ED are still needed to evaluate the ideal patient population to whom these PCAs may provide the most benefit as well as a robust cost-analysis to ensure feasibility of use in the future.

Identifying non-invasive methods for anxiolysis is becoming increasingly important in the pediatric emergency department (ED). Few studies have examined the use of intranasal (IN) ketamine for procedural anxiolysis. We aim to evaluate if IN ketamine provides satisfactory anxiolysis for patients undergoing laceration repair based on anxiety and sedation scoring. We also evaluated the feasibility of using IN ketamine in future trials based on its tolerability and side-effects. A pilot study evaluating IN ketamine in the treatment of procedural anxiety for patients, 2 years and older, weighing 40 kg or less, presenting to the pediatric ED with lacerations. The need for anxiolysis was defined by an elevated modified-Yale Preoperative Anxiety Scale—Short Form (mYPAS-SF) score. Patients received 5 mg/kg of IN ketamine in addition to topical anesthesia, mYPAS-SF scoring before and during the procedure, sedation scoring, adverse events, vital signs, age, weight, laceration size and location, and satisfaction surveys were recorded. Twenty-five patients were enrolled, with mean age of 61 ± 29.2 months and mean weight of 21 ± 6.4 kg. Lacerations were located on the face, extremities, and groin with mean size of 2.1 cm. A decrease in anxiety levels was observed, from median m-YPAS-SF score of 66.7 (62.50–80.2) to 33.3 (27.09–52.00), p

Bystander CPR (B-CPR) is known to be a critical action in treating out-of-hospital cardiac arrest (OHCA). Immediate CPR may double a patient's chance of survival. Only 40% of OHCA patients receive B-CPR (Cardiac Arrest Registry to Enhance SurvivalWe hypothesize that of OHCA patients receiving B-CPR, there is a gender disparity favoring males.This is a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) dataset. 149,734 cases were included in this analysis. Primary outcome was frequency of B-CPR between genders. Secondary analysis included gender disparity in AED pad placement, and subsets divided by type of bystander.Among 149,734 OHCA, 78,738 received B-CPR. 28,485 of 55,215 females (51.59%) received B-CPR, compared to 50,253 of 94,519 males (53.17%, p 0.001). Of OHCA with bystander AED pad placement, 22.9% of females had AED pads applied, compared to 24.6% of males (p 0.001). In OHCA witnessed by family member, 57.80% of females versus 61.70% of males received B-CPR (p 0.001). In OHCA witnessed by layperson, 62.50% of females versus 69.00% of males received B-CPR (p 0.001).There was a significantly lower rate of B-CPR in women experiencing OCHA in the population sample analyzed. Continued education and research are needed on the topic to address gender-specific differences in OHCA.

The objective was to compare the failure rate of incision and drainage (ID) with LOOP technique versus ID with standard packing technique in adults and children presenting to the emergency department (ED) with subcutaneous abscess.This prospective, randomized controlled trial (NCT03398746) enrolled a convenience sample of patients presenting to two Level 1 trauma centers over 12 months with skin abscesses. Of 256 patients screened, 217 patients were enrolled, 109 randomized to ID with packing (50%) and 108 (50%) to ID with LOOP. The primary outcome was treatment failure defined by admission, IV antibiotics, or repeat drainage within 10-day follow-up. The secondary outcomes included ease of procedure, ease of care, pain, and satisfaction using a 10-point numeric rating scale.There were no differences in patient characteristics between groups. Follow-up data were available in 196 (90%). Treatment failure occurred in 20% (range = 12%-28%) of packing patients and 13% (range = 6%-20%) of LOOP patients (p = 0.25). There were no significant differences in failure rates in adults (p = 0.82), but there was a significant difference in children (age ≤ 18 years) at 21% (range = 8%-34%) in the packing group and 0 (0%) in the LOOP group (p = 0.002). Operators reported no significant differences in ease of procedure between techniques (p = 0.221). There was significantly less pain at follow-up in the LOOP group versus packing (p = 0.004). The wound was much easier to care for over the first 36 hours in the LOOP group (p = 0.002). Patient satisfaction at 10 days postprocedure was significantly higher in the LOOP group (p = 0.005).The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.

Background Rapid identification of patients with occult injury and illness in the emergency department can be difficult. Transcutaneous carbon dioxide (TCO2) and oxygen (TO2) measurements may be non‐invasive surrogate markers for the identification of such patients. Objectives To determine if TCO2 or TO2 are useful adjuncts for identifying severe illness and the correlation between TCO2, lactate, and end tidal carbon dioxide (ETCO2). Methods Prospective TCO2 and TO2 measurements at a tertiary level 1 trauma center were obtained using a transcutaneous sensor on 300 adult patients. Severe illness was defined as death, intensive care unit (ICU) admission, bilevel positive airway pressure, vasopressor use, or length of stay >2 days. TCO2 and TO2 were compared to illness severity using t tests and correlation coefficients. Results Mean TO2 did not differ between severe illness (58.9, 95% CI 54.9–62.9) and non‐severe illness (58.0, 95% CI 54.7–61.1). Mean TCO2 was similar between severe (34.6, 95% CI 33–36.2) vs non‐severe illness (35.9, 95% CI 34.7–37.1). TCO2 was 28.7 (95% CI 24.0–33.4) for ICU vs. 35.9 (95% CI 34.9–36.9) for non‐ICU patients. The mean TCO2 in those with lactate > 2.0 was 29.8 (95% CI 25.8–33.8) compared with 35.7 (95% CI 34.9–36.9) for lactate

Introduction There are no emergent pharmaceutical interventions for acute suicidal ideation, a common presenting complaint in the ED. Ketamine is a NMDA agonist frequently used by ED physicians for sedation and analgesia. Prior evidence from studies conducted in inpatient psychiatry units suggests that ketamine may have a role in alleviating treatment-resistant depression as well as suicidal ideation. Methods PubMed, MEDLINE, and Cochrane reviews were queried for articles related to keywords ketamine, suicidality, suicidal ideation, and emergency department/room. Relevant articles were selected and reviewed by two separate authors. Results Three relevant, prospective studies were identified with a mean sample size of 25.7. Each was performed using 0.2 mg/kg ketamine for individuals receiving active treatment. Each study reported a decrease in depressive symptoms among those receiving ketamine. One study reported a significant reduction in SI when compared to placebo at 90 min that became non-significant by 230 min. No significant adverse events were reported in any study. Conclusion Current evidence suggests that ketamine is a promising, safe potential intervention for acute suicidality in the ED. Convincing evidence for efficacy of ketamine for acute suicidal ideation remains lacking, and this promising potential intervention should be further investigated.

Background:Early identification of diabetic ketoacidosis (DKA) may improve clinical outcomes. Prior studies suggest exhaled end tidal carbon dioxide (ETCO2) provides a non-invasive, real-time method to screen for DKA in the emergency department (ED).Methods:This a retrospective cohort study among patients who activated Emergency Medical Services (EMS) during a one-year period. Initial out-of-hospital vital signs documented by EMS personnel, including ETCO2 and first recorded blood glucose level (BGL), as well as in-hospital records, including laboratory values and diagnosis, were collected. The main outcome was the association between ETCO2 and the diagnosis of DKA.Results:Of the 118 patients transported with hyperglycemia (defined by BGL >200), six (5%) were diagnosed with DKA. The mean level of ETCO2 in those without DKA was 35mmHg (95% CI, 33-38mmHg) compared to mean levels of 15mmHg (95% CI, 8-21mmHg) in those with DKA (P Conclusion:Among patients with hyperglycemia, prehospital levels of ETCO2 were significantly lower in patients with DKA compared to those without and were predictive of the diagnosis of DKA. Furthermore, out-of-hospital ETCO2 was significantly correlated with measures of metabolic acidosis.

OBJECTIVE Postresuscitation debriefing (PRD) addresses Accreditation Council for Graduate Medical Education core competencies and is recommended by the American Heart Association. Postresuscitation debriefing improves resuscitation outcomes, promotes team morale, supports emotional well-being, and reduces burnout. Despite these benefits, PRD occurs infrequently. Commonly cited barriers to PRD include lack of training and comfort in facilitating PRD. We are unaware of any video-based educational tools that train physicians in PRD. We aimed to evaluate the impact of an educational tool on the frequency of PRD using a before- and after-study design. METHODS We created and distributed a 20-minute, video-based educational tool via youtube.com on PRD to pediatric emergency medicine (EM) fellows, pediatric EM attendings, senior EM residents, and EM attending physicians. Participants completed web-based surveys before, immediately after, and 3 months after watching the tool. We analyzed the effects of participation on PRD knowledge, comfort conducting PRD, and frequency of PRD performance. RESULTS Thirty-five (63%) of 56 participants completed all 3 surveys. Participation in our study showed significant improvements in reported frequency of performing PRD (23% presurvey, 38% follow-up survey; 95% confidence interval [CI], 2%-29%; P = 0.03), perceived knowledge of PRD (odds ratio, 6.1; 95% CI, 3.05-12.29; P < 0.001), and comfort in conducting PRD (odds ratio, 3.7; 95% CI, 1.96-7.03; P < 0.001). Most respondents (94%) reported that the tool was worthwhile. Most (83%) would recommend the tool to colleagues, and 86% reported positive effects on their teams with PRD. CONCLUSIONS Implementation of a video-based educational tool on PRD in the emergency department was associated with increased provider report of PRD frequency, knowledge, and comfort level.

Background: End-tidal carbon dioxide (EtCO2) measurement has been shown to have prognostic value in acute trauma. Objective: Evaluate the association of prehospital EtCO2 and in-hospital mortality in trauma patients and to assess its prognostic value when compared to traditional vital signs. Methods: Retrospective, cross-sectional study of patients transported by a single EMS agency to a level one trauma center. We evaluated initial out-of-hospital vital signs documented by EMS personnel including EtCO2, respiratory rate (RR), systolic BP (SBP), diastolic BP (DBP), pulse (P), and oxygen saturation (O2) and hospital data. The main outcome measure was mortality. Results: 135 trauma patients were included; 9 (7%) did not survive. The mean age of patients was 40 (SD17) [Range 16–89], 97 (72%) were male, 76 (56%) were admitted to the hospital and 15 (11%) went to the ICU. The mean EtCO2 level was 18 mmHg (95%CI 9–28) [Range 5–41] in non-survivors compared to 34 mmHg (95%CI 32–35) [Range 11–51] in survi...

Background Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. Methods We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO 2 ) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. Results 106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO 2 values ranging 2–113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO 2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98–1.00) and 100% specificity (PPV 1.0, 95%CI 0.93–1.00). Conclusion Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.

Objective The objective was to compare test characteristics of a single serum concentration of glial fibrillary acidic protein (GFAP), S-100β, and ubiquitin carboxyl terminal hydrolase L1 (UCH-L1), obtained within 6 hours of head injury, to diagnose mild traumatic brain injury (mTBI) in head-injured subjects. Methods Adults aged 18 to 80 years who presented to one of seven EDs with a blunt closed head injury underwent head CT within 4 hours of injury and had blood drawn for biomarker analysis within 6 hours of injury were eligible. Subjects were considered to have mTBI if they had an initial Glasgow Coma Scale (GCS) > 13 and met one or more of the following criteria: loss of consciousness (LOC), posttraumatic amnesia, or confusion. Subjects with mTBI and an abnormal head computed tomography (CT) scan were categorized as complicated mTBI; those with a normal head CT were categorized as uncomplicated mTBI; and subjects with a GCS = 15, no LOC, no posttraumatic amnesia, and no confusion were considered to not have a mTBI. Biomarker concentration measurements for GFAP and UCH-L1 were performed using an enzyme-linked immunosorbent assay. S-100β concentration was determined using an electrochemiluminescence immunoassay. Median biomarker concentration for each group was compared using the Kruskal-Wallis test. Logistic regression was used to determine area under the receiver operating curve (AUC) for each of the three biomarkers. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and negative and positive likelihood ratios (LRs) for the three biomarkers to differentiate between complicated mTBI, uncomplicated mTBI, and no mTBI were calculated. Results A total of 247 subjects were enrolled and had adequate clinical and biomarker information for analysis. A total of 188 met criteria for mTBI, with 34 (18.1%) having an acute abnormality on CT (complicated mTBI). The mean (±SD) age of the study population was 45.8 (±17.3) years, and 59.9% were male. Median serum concentrations for all biomarkers were significantly different between groups, lowest in the no mTBI group, and progressively increasing in the uncomplicated and complicated mTBI groups (p

Objectives: We compared Sort, Assess, Lifesaving Intervention, Treatment / Transport (SALT) and Simple Triage and Rapid Treatment (START) triage methodologies to a published reference standard, and evaluated the accuracy of the START method applied by emergency medical services (EMS) personnel in a field simulation. Design: Simulated mass casualty incident (MCI). Paramedics trained in START triage assigned each victim to green (minimal), yellow (delayed), red (immediate), or black (dead) categories. These victim classifications were recorded by investigators and compared to reference standard definitions of each triage category. The victim scenarios were also compared to the a priori classifications as developed by the investigators. Setting: MCI field simulation. Main outcome measure: Comparison of the correlation of START and SALT triage methodologies to reference standard definitions. Another outcome measure was the accuracy of the application of START triage by EMS personnel in the field exercise. Results: The strongest correlation to the reference standard was SALT with an r = 0.860 (p < 0.001) and κ = 0.632 (p < 0.001). START and SALT triage systems agreed 100 percent on both black and green classifications. There were significant correlations between the field triage and both START and SALT methods (p < 0.001, respectfully). SALT had a significantly lower undertriage rate (9 percent [95%CI 2-15]) than both START (20 percent [95%CI 11-28]) and field triage (37 percent [95%CI 24-52]). There were no significant differences in overtriage rates. Conclusions: In our study, the SALT triage system was overall more accurate triage method than START at classifying patients, specifically in the delayed and immediate categories. In our field exercise, paramedic use of the START methodology yielded a higher rate of undertriage compared to the SALT classification.

Introduction:Atrial fibrillation (AFIB) with rapid ventricular response (RVR) is a common tachydysrhythmia encountered by Emergency Medical Services (EMS). Current guidelines suggest rate control in stable, symptomatic patients.Problem:Little is known about the safety or efficacy of rate-controlling medications given by prehospital providers. This study assessed a protocol for prehospital administration of diltiazem in the setting of AFIB with RVR for provider protocol compliance, patient clinical improvement, and associated adverse events.Methods:This was a retrospective, cohort study of patients who were administered diltiazem by providers in the Orange County EMS System (Florida USA) over a two-year period. The protocol directed a 0.25mg/kg dose of diltiazem (maximum of 20mg) for stable, symptomatic patients in AFIB with RVR at a rate of >150 beats per minute (bpm) with a narrow complex. Data collected included patient characteristics, vital signs, electrocardiogram (ECG) rhythm before and after diltiazem, and need for rescue or additional medications. Adverse events were defined as systolic blood pressure Results:Over the study period, 197 patients received diltiazem, with 131 adhering to the protocol. The initial rhythm was AFIB with RVR in 93% of the patients (five percent atrial flutter, two percent supraventricular tachycardia, and one percent sinus tachycardia). The agreement between prehospital and physician rhythm interpretation was 92%, with a Kappa value of 0.454 (P Conclusion:This study suggests that prehospital diltiazem administration for AFIB with RVR is safe and effective when strict protocols are followed.Rodriguez A, Hunter CL, Premuroso C, Silvestri S, Stone A, Miller S, Zuver C, Papa L. Safety and efficacy of prehospital diltiazem for atrial fibrillation with rapid ventricular response.Prehosp Disaster Med.2019;34(3):297–302.

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Objectives Compliance with recommended follow-up from the pediatric emergency department (PED) has been shown to be poor. This study evaluated whether a text message reminder to the caregivers after discharge from the PED improved compliance with recommended primary care follow-up. Methods This was a blinded randomized control trial conducted at a level 1 pediatric trauma center. The intervention was a text message sent to the caregiver within 24 hours of discharge from the PED reminding them to follow up with their primary care doctor. Patients were eligible if the caregiver had text message capability on their cellular phones, they were currently established patients of the organization's Pediatric Faculty Practice, they were discharged home from the PED, and they were referred for follow-up within 1 week of discharge by the pediatric emergency physician. After informed consent, pediatric patients were randomized to either an intervention group (text message appointment reminder) or a control group (standard scheduling with no reminder). The patient, treating physician, and primary care outpatient center were blinded to the group assignment. Enrollment occurred 24 hours per day and 7 days per week. Results There were 123 patients enrolled in the study, 62 patients randomized to the control group (standard scheduling) and 61 randomized to the intervention group (text message appointment reminder). Of the patients, 58% were male and 42% were female, with the average age of the patients being 2.2 years (SD, 2.8). The majority of patients were seen in the PED on a weekday, with 24% presenting on a weekend. Only 28% of patients completed the recommended follow-up, and the average time from PED discharge to follow-up was 6 days (SD, 4.2; range, 0-17 days). There was no significant difference in follow-up in the standard treatment group (19/62, 31%) versus the text message intervention group (16/61, 26%) (P = 0.69; rate ratio, 0.94; 95% confidence interval, 0.75-1.18). When we assessed other variables, we found that parents of younger children were more likely to follow up as recommended by the pediatric ED physician. Of those who were compliant with follow-up, we found a mean age of 1.3 years (SD, 2.0; range, 0.8-9.1) versus 2.6 years (SD, 3.0; range, 0.08-15.3) for those who were not compliant with follow-up (P = 0.02). Conclusions In this randomized controlled study, a text message reminder to caregivers did not improve compliance for PED patients. However, caregivers of younger children were more likely to complete follow-up as recommended by the PED physician compared with caregivers of older children.

Objectives This study examined the performance of serum glial fibrillary acidic protein (GFAP) in detecting traumatic intracranial lesions on computed tomography (CT) scan in children and youth with mild and moderate traumatic brain injury (TBI) and assessed its performance in trauma control patients without head trauma. Methods This prospective cohort study enrolled children and youth presenting to three Level I trauma centers following blunt head trauma with Glasgow Coma Scale (GCS) scores of 9 to 15, as well as trauma control patients with GCS scores of 15 who did not have blunt head trauma. The primary outcome measure was the presence of intracranial lesions on initial CT scan. Blood samples were obtained in all patients within 6 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP (ng/mL). Results A total of 257 children and youth were enrolled in the study and had serum samples drawn within 6 hours of injury for analysis: 197 had blunt head trauma and 60 were trauma controls. CT scan of the head was performed in 152 patients and traumatic intracranial lesions on CT scan were evident in 18 (11%), all of whom had GCS scores of 13 to 15. When serum levels of GFAP were compared in children and youth with traumatic intracranial lesions on CT scan to those without CT lesions, median GFAP levels were significantly higher in those with intracranial lesions (1.01, interquartile range [IQR] = 0.59 to 1.48) than those without lesions (0.18, IQR = 0.06 to 0.47). The area under the receiver operating characteristic curve (AUC) for GFAP in detecting children and youth with traumatic intracranial lesions on CT was 0.82 (95% confidence interval [CI] = 0.71 to 0.93). In those presenting with GCS scores of 15, the AUC for detecting lesions was 0.80 (95% CI = 0.68 to 0.92). Similarly, in children under 5 years old the AUC was 0.83 (95% CI = 0.56 to 1.00). Performance for detecting intracranial lesions at a GFAP cutoff level of 0.15 ng/mL yielded a sensitivity of 94%, a specificity of 47%, and a negative predictive value of 98%. Conclusions In children and youth of all ages, GFAP measured within 6 hours of injury was associated with traumatic intracranial lesions on CT and with severity of TBI. Further study is required to validate these findings before clinical application.

This study assesses outcome in pediatric patients with skin abscess using the LOOP compared to the standard incision and drainage (ID) with packing method.This retrospective study used ICD-9 codes to identify pediatric patients aged 0 to 17 years with a skin abscess presenting to a level I pediatric trauma emergency department (ED). Patients requiring surgical debridement were excluded; as were patients with abscesses on the face, scalp, hands or feet. The primary outcome was failure rate, defined as those requiring admission, intravenous antibiotics, or repeat drainage.Over a 1-year period there were 233 pediatric abscesses identified: 79 cases (34%) treated with the LOOP technique and 154 cases with standard ID (66%). The overall mean age of patients was 6.2 yrs: children in the LOOP group were younger than those in the standard group, 4.4 vs 7.1 years respectively (P=.001). Abscess location also differed between the two groups; however they had a similar gender distribution and mean temperature. Of the cases identified by chart review, clinical outcome could be assessed in 143 patients (61%): 52 (36%) patients with LOOP vs 91 (64%) with ID. Failure rate was 1.4% in the LOOP group and 10.5% in the standard ID (P.030).There was a significant difference in failure rate between the LOOP and the standard ID groups. A prospective randomized trial is needed to confirm these results, but this novel technique shows promise as an alternative to ID with packing in the management of skin abscesses in pediatric ED patients.

This study assessed roadside and bedside factors associated with early mortality following motor vehicle trauma.This retrospective cohort study evaluated motor vehicle crashes in Orange County Florida in 2009 that became medical examiner cases. Data from the Department of Highway Safety and Motor Vehicles (DHSMV), emergency medical services (EMS), a level I trauma center, and the medical examiner were integrated for the analysis. The primary outcome measure was early death, defined by death within 48 hours of a motor vehicle trauma. Both traditional and nontraditional predictors of early mortality were assessed.The most significant factors associated with early mortality were as follows: (1) From autopsy: hemothorax (odds ratio [OR] = 8.26, 95% confidence interval [CI]: 1.83-37.3) and liver injury (OR = 4.26, 95% CI: 1.70-15.6); (2) from hospital data: systolic blood pressure (OR = 0.98, 95% CI: 0.96-0.99) and having cardiopulmonary resuscitation (CPR) performed in the emergency department (OR = 13.4, 95% CI: 1.51-118.72); and (3) from DHSMV: involvement of drugs and/or alcohol (OR = 4.27, 95% CI: 1.33-13.6), total fatalities (OR = 6.07, 95% CI: 1.57-23.5), speed of vehicle (OR = 1.06, 95% CI: 1.02-1.09), and number of lanes at the crash scene (OR = 1.58, 95% CI: 1.13-2.20).These results were made possible by integrating 4 distinct data sources. As future research in traffic-related injury moves toward prevention, it will be critical to evaluate new preventative strategies quickly and effectively. A unique number that is both patient and event specific that could be incorporated into each of these databases would make such integration seamless. Successful methods for linking data collected by the multiple agencies involved in motor vehicle collisions will ultimately provide invaluable information for medical personnel, researchers, engineers, planners, and policy makers at the local, state, and national levels to identify safety priorities to reduce crash-related injuries and fatalities.

Exhaled end-tidal carbon dioxide (ETCO(2)) concentration is associated with lactate levels in febrile patients. We assessed the association of ETCO(2) with mortality and lactate levels in patients with suspected sepsis.This was a prospective observational study. We enrolled 201 adult patients presenting with suspected infection and 2 or more systemic inflammatory response syndrome criteria. Lactate and ETCO(2) were measured and analyzed with patient outcomes.The area under the receiver operator characteristics curve (AUC) was 0.75 (confidence interval [CI], 0.65-0.86) for lactate and mortality and 0.73 (CI, 0.61-0.84) for ETCO(2) and mortality. When analyzed across the different categories of sepsis, the AUCs for lactate and mortality were 0.61 (CI, 0.36-0.87) for sepsis, 0.69 (CI, 0.48-0.89) for severe sepsis, and 0.74 (CI, 0.55-0.93) for septic shock. The AUCs for ETCO(2) and mortality were 0.60 (CI, 0.37-0.83) for sepsis, 0.67 (CI, 0.46-0.88) for severe sepsis, and 0.78 (CI, 0.59-0.96) for septic shock. There was a significant inverse relationship between ETCO(2) and lactate in all categories, with correlation coefficients of -0.421 (P.001) in the sepsis group, -0.597 (P.001) in the severe sepsis group, and -0.482 (P = .011), respectively. Adjusted odds ratios were calculated, demonstrating 3 significant predictors of mortality: use of vasopressors 16.4 (95% CI, 1.80-149.2), mechanical ventilation 16.4 (95% CI, 3.13-85.9), and abnormal ETCO(2) levels 6.48 (95% CI, 1.06-39.54).We observed a significant association between ETCO(2) concentration and in-hospital mortality in emergency department patients with suspected sepsis across a range of disease severity.

ACADEMIC EMERGENCY MEDICINE 2012; 19:2–10 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with “clinically important” brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15. Methods: This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of “any traumatic intracranial injury” on CT. Secondary outcomes included “clinically important brain injury” on CT and need for neurosurgical intervention. Results: Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had “clinically important” brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For “clinically important” brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention. Conclusions: In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

The ability of emergency care research (ECR) to produce meaningful improvements in the outcomes of acutely ill or injured patients depends on the optimal configuration, infrastructure, organization, and support of emergency care research networks (ECRNs). Through the experiences of existing ECRNs, we can learn how to best accomplish this. A meeting was organized in Washington, DC, on May 28, 2008, to discuss the present state and future directions of clinical research networks as they relate to emergency care. Prior to the conference, at the time of online registration, participants responded to a series of preconference questions addressing the relevant issues that would form the basis of the breakout session discussions. During the conference, representatives from a number of existing ECRNs participated in discussions with the attendees and provided a description of their respective networks, infrastructure, and challenges. Breakout sessions provided the opportunity to further discuss the strengths and weaknesses of these networks and patterns of success with respect to their formation, management, funding, best practices, and pitfalls. Discussions centered on identifying characteristics that promote or inhibit successful networks and their interactivity, productivity, and expansion. Here the authors describe the current state of ECRNs and identify the strengths, weaknesses, and potential pitfalls of research networks. The most commonly cited strengths of population- or disease-based research networks identified in the preconference survey were access to larger numbers of patients; involvement of physician experts in the field, contributing to high-level study content; and the collaboration among investigators. The most commonly cited weaknesses were studies with too narrow a focus and restrictive inclusion criteria, a vast organizational structure with a risk of either too much or too little central organization or control, and heterogeneity of institutional policies and procedures among sites. Through the survey and structured discussion process involving multiple stakeholders, the authors have identified strengths and weaknesses that are consistent across a number of existing ECRNs. By leveraging the strengths and addressing the weaknesses, strategies can be adopted to enhance the scientific value and productivity of these networks and give direction to future ECRNs.

Objective: We created an instructional waiting room video that explained what patients should expect during their emergency department (ED) visit and sought to determine whether preparing patients using this video would 1) improve satisfaction, 2) decrease perceived waiting room times and 3) increase calls to an outpatient referral line in an ambulatory population. Methods: This serial cross-sectional study took place over a period of 2 months before (control) and 2 months after the introduction of an educational waiting room video that described a typical patient visit to our ED. We enrolled a convenience sample of adult patients or parents of pediatric patients who were triaged to the ED waiting room; a research assistant distributed and collected the surveys as patients were being discharged after treatment. Subjects were excluded if they were admitted. The primary outcome was overall satisfaction measured on a 5-point Likert scale, and secondary outcomes included perceived waiting room time, and the number of outpatient referral-line calls. Results: There were 1132 subjects surveyed: 551 prevideo and 581 postvideo. The mean age was 38 years (standard deviation [SD] 18), 61% were female and the mean ED length of stay was 5.9 hours (SD 3.6). Satisfaction scores were significantly higher postvideo, with 65% of participants ranking their visit as either “excellent” or “very good,” compared with 58.1% in the prevideo group (p = 0.019); however, perceived waiting room time was not significantly different between the groups (p = 0.24). Patient calls to our specialty outpatient clinic referral line increased from 1.5 per month (95% confidence interval [CI] 0.58–2.42) to 4.5 per month (95% CI 1.19–7.18) (p = 0.032). After adjusting for possible covariates, the most significant determinants of overall satisfaction were perceived waiting room time (odds ratio [OR] 0.41, 95% CI 0.34–0.48) and having seen the ED waiting room video (OR 1.41, 95% CI 1.06–1.86). Conclusion: Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population. Future studies should research the implementation of this educational intervention in a randomized fashion.

Objectives: To evaluate the progression in productivity of emergency medicine (EM) residents by post-graduate year, as measured by hourly work in relative value units (RVUs).Methods: This retrospective study was conducted at an Accreditation Council for Graduate MedicalEducation (ACGME)-accredited EM residency with a postgraduate year (PGY) 1-2-3 configuration. A queryof an electronic billing database composed of more than 230,000 visits from academic years July 2003 toDecember 2006, representing at least four classes at each PGY level, was conducted. The main outcomewas change in productivity in RVUs generated per hour, compared by resident PGY level. This measureencompasses not only volume of patients seen but also patient acuity in terms of evaluation and manage-ment services and procedures provided and supported by documentation adequate for coding. Descriptivestatistics and Tukey’s test were used for data analysis.Results: Over the three-year study period, 70 EM residents were assessed at various levels of training. Pro-ductivity, as measured by mean RVUs generated per hour, was 2.51 (95% confidence interval [CI] = 2.20 to2.82) for PGY-1 residents, 3.51 (95% CI = 3.12 to 3.90) for PGY-2 residents, and 3.61 (95% CI = 3.41 to 3.80)for PGY-3 residents (p < 0.001). Patient acuity (RVUs generated per patient) increased 5%–8% with eachPGY progression: 3.05 (95% CI = 2.96 to 3.13) for PGY-1, 3.20 (95% CI = 3.09 to 3.31) for PGY-2, and 3.46(95% CI = 3.42 to 3.50) for PGY-3 (p < 0.001). There was a statistically significant increase in productivity(p < 0.001) and acuity (p = 0.03) from PGY-1 to PGY-2, with acuity also increasing between PGY-2 andPGY-3 (p < 0.001).Conclusions: Hourly work productivity and acuity increased with experience within this ACGME-accredited EM residency. The progression in workload and acuity by PGY is measurable and commensu-rate with the graduated level of responsibility desired in an EM program.ACADEMIC EMERGENCY MEDICINE 2007; 14:790–794 a 2007 by the Society for Academic EmergencyMedicineKeywords: productivity, relative value scale, emergency medicine, residency and internship

The establishment of trauma systems was anticipated to improve overall survival for the severely injured patient. We systematically reviewed the published literature to assess if outcome from severe traumatic injury is improved for patients following the establishment of a trauma system.A systematic literature review of all population-based studies that evaluated trauma system performance was conducted. A qualitative analysis of each study's design and methodology and a meta-analysis was performed to evaluate the evidence to date of trauma system effectiveness.A search of the literature yielded 14 published articles. Trauma systems demonstrated improved odds of survival in 8 of the 14 reports. The overall quality-weighted odds ratio was 0.85 lower mortality following trauma system implementation.The results of the meta-analysis showed a 15% reduction in mortality in favor of the presence of a trauma system. Evaluation of trauma system effectiveness must remain an uncompromising commitment to optimal outcome for the injured patient.

Objectives: In preparation for the World Congress on Drowning uniform reporting consensus document of drowning incidents we reviewed systematically the medical literature for the terms and definitions used to describe drowning incidents to assess the uniformity of these terms in the medical literature. Methods: The search strategy included a literature search of PubMed ® , MEDLINE ® and the Cochrane Database from 1966 to April 2002, as well as a review of reference lists of identified studies and a hand search of relevant textbooks and reference works. Search terms used included drowning, near-drowning, submersion, immersion, suffocation, asphyxiation, water injuries, and aspiration. Any article with drowning as a primary focus and containing a definition of drowning was included. Study designs included experimental studies, observational studies, case control studies, reviews, letters, and editorials. Results: The search identified approximately 6000 articles. Of these 650 were reviewed and 43 articles addressing the definition of drowning were identified. We found a total of 33 different definitions to describe drowning incidents, 20 for drowning and 13 for near-drowning; along with another 13 related terms. There were at least 20 different outcome measures for drowning incidents reported. Conclusions: A review of existing drowning literature demonstrates a lack of a standard definition of drowning and a lack of agreement on measures of outcome. This variability in definitions and outcomes makes it very difficult to assess and analyze studies both individually and as a whole and draw conclusions that will influence practice. These objective findings support the need for the drowning Utstein focus on one definition of drowning and validated measures of functional and neurological outcome.

Objective: We assessed the impact of emergency department (ED) paramedic staffing on emergency medical services (EMS) unit offload time, an intervention designed to assist with EMS unit patient offload when the ED is at full bed capacity. Methods: This prospective pre/post intervention study assessed patients offloaded via the regional EMS system at an urban tertiary care teaching hospital. Three groups were compared: 1) a pre-paramedic group with data obtained prior to any paramedics staffing the ED; 2) a transition (control) group with data obtained during paramedic orientation; and 3) a post-paramedic group with data measured after paramedics were staffing the ED. Research assistants stationed in the ambulance bay of the ED enrolled a convenience sample of patients for seven consecutive days and recorded offload time as patients were brought in by EMS. The primary outcome measure was offload time (the interval between patient arrival via EMS and transfer of patient care to an ED stretcher). Results: A total of 519 offloaded patients were assessed: 207 in the pre-paramedic period, 93 in the transition (control) period and 219 in the post-paramedic period. Overall median offload times (in minutes) in the preparamedic and post-paramedic groups were 10 [IQR 4-32] versus 4 [IQR 1-16] respectively (p

Differentiating between cardiac and obstructive causes for dyspnoea is essential for proper management, but is difficult in the prehospital setting.To assess if prehospital levels of end-tidal carbon dioxide (ETCO2) differed in obstructive compared to cardiac causes of dyspnoea, and could suggest one diagnosis over the other.We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period who were diagnosed with either obstructive pulmonary disease or congestive heart failure (CHF) by ICD-9 codes. Initial prehospital vital signs, including ETCO2, were recorded. Records were linked by manual archiving of emergency medical services and hospital data.There were 106 patients with a diagnosis of obstructive or cardiac causes of dyspnoea that had prehospital ETCO2 levels measured during the study period. ETCO2 was significantly lower in patients diagnosed with CHF (31 mm Hg 95% CI 27 to 35) versus obstructive pulmonary disease (39 mm Hg 95% CI 35 to 42; p0.001). Lower ETCO2 levels predicted CHF, with an area under the Receiver Operating Characteristics Curve of 0.70 (95% CI 0.60 to 0.81). Using ETCO240 mm Hg as a cut-off, the sensitivity for predicting heart failure was 93% (95% CI 88% to 98%), the specificity was 43% (95% CI 33% to 52%), the positive predictive value was 38% (95% CI 29% to 48%), and the negative predictive value was 94% (95% CI 89% to 99%).Lower levels of ETCO2 were associated with CHF, and may serve as an objective diagnostic adjunct to predict this cause of dyspnoea in the prehospital setting.

Cutaneous infestation by the human botfly, Dermatobia hominis, results in furuncular myiasis. This condition is endemic to the forested areas of Mexico, Central and South America. However, because of widespread travel, furuncular myiasis has become more common in North America. Misdiagnosis and mismanagement can occur owing to limited awareness of the condition outside endemic areas. To our knowledge, there is only a single report of botfly myiasis in the recent emergency medicine literature, which is surprising since the emergency department is likely to be the place many patients with this condition first seek attention. We present and discuss the case of a 50-year-old man with furuncular myiasis acquired in Belize. Parasitic infestation should be included in the differential diagnosis of a new skin lesion in patients who have travelled to endemic areas.

Objective To determine the ability of prehospital end-tidal carbon dioxide (ETCO 2 ) to predict in-hospital mortality compared to conventional vital signs. Methods We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period. Included patients had ETCO 2 recorded in addition to initial vital signs. The main outcome was death at any point during hospitalization. Secondary outcomes included laboratory results and admitting diagnosis. Results Of 1328 records reviewed, hospital discharge data, ETCO 2 , and all 6 prehospital vital signs were available in 1088 patients. Low ETCO 2 levels were the strongest predictor of mortality in the overall group (area under the receiver operating characteristic curve (AUC of 0.76, 95% confidence interval [CI] 0.66-0.85), as well as subgroup analysis excluding prehospital cardiac arrest (AUC of 0.77, 95% CI 0.67-0.87). The sensitivity of abnormal ETCO 2 for predicting mortality was 93% (95% CI 79%-98%), the specificity was 44% (95% CI 41%-48%), and the negative predictive value was 99% (95% CI 92%-100%). There were significant associations between ETCO 2 and serum bicarbonate levels ( r = 0.429, P r = −0.216, P P Conclusion Of all prehospital vital signs, ETCO 2 was the most predictive and consistent for mortality, which may be related to an association with metabolic acidosis.

We examined the agreement between a videoconference-based evaluation and a bedside evaluation in the management of acute traumatic wounds in an emergency department. Adult and paediatric patients with acute wounds of various severities to the face, trunk and/or extremities presenting to the emergency department within 24 hours of injury were enrolled. Research assistants transmitted video images of the wound to an emergency physician using a laptop computer. The physician completed a standard wound assessment form before conducting a bedside evaluation and then completing a second assessment form. The primary outcome measure was wound length and depth. We also assessed management decision-making. A total of 173 wounds were evaluated. The correlation coefficient between video and bedside assessments was 0.96 for wound length. The mean difference between the lengths was 0.02 cm (SD 0.91). Management of the wound would have been the same in 94% of cases. The agreement on wound characteristics and wound management ranged from 84-100%. The highest correlation was 0.92 in suture material used and the lowest correlation was 0.64 in wound type. The ability of video images to distinguish between a minor and non-minor wound, and predicting the need for hospital management, had high degrees of sensitivity and specificity. The study showed that wound characteristics and management decisions appear to correlate well between video and bedside evaluations.

There are an estimated 10 million people affected annually by traumatic brain injury (TBI) across the globe.1 In the United States, TBI is a major cause of death and disability2 with about 52,000 annual deaths and 5.3 million Americans impaired by its effects. TBI is a contributing factor to over 30% of all injury-related deaths in the United States and it has been referred to as the silent epidemic of our time. 3, 4 European TBI prevalence data is not consistently reported by each country but it has been estimated that 1.6 million head-injured patients are hospitalized annually in Europe with an incidence rate of about 235 per 100,000. There is an average mortality rate of about 15 per 100,000 and a case fatality rate of about 11 per 100. The TBI severity ratio of hospitalized patients is about 22:1.5:1 for mild vs. moderate vs. severe cases, respectively.5 According to the World Health Organization, TBI will surpass many diseases as the major cause of death and disability by the year 2020.1 Brain injuries can be focal, diffuse or a combination of focal and diffuse. The degree of brain injury depends on the primary mechanism/magnitude of injury, secondary insults and the patient’s genetic and molecular response. Following the initial injury, cellular responses and neurochemical and metabolic cascades contribute to secondary injury.6, 7 Focal brain injuries include contusions, brain lacerations, and hemorrhage leading to the formation of hematoma in the extradural, subarachnoid, subdural, or intracerebral compartments within the head. Traumatic brain injury represents a spectrum of injury severity. The number, types, and location of lesions as well as the magnitude of overlapping injuries across this spectrum of injury severity are still not clearly described and are challenging to classify. There are two aspects to injury caused by TBI the damage caused by the initial impact or insult, and that which may subsequently evolve over the ensuing hours and days referred to as secondary insults. Secondary insults can be mediated through physiologic events which decrease supply of oxygen and energy to the brain tissue or through a cascade of cytotoxic events. These events are mediated by many molecular and cellular processes.

Study objective This study examines whether serum levels of glial fibrillary acidic protein breakdown products (GFAP-BDP) are elevated in patients with mild and moderate traumatic brain injury compared with controls and whether they are associated with traumatic intracranial lesions on computed tomography (CT) scan (positive CT result) and with having a neurosurgical intervention. Methods This prospective cohort study enrolled adult patients presenting to 3 Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 9 to 15. Control groups included normal uninjured controls and trauma controls presenting to the emergency department with orthopedic injuries or a motor vehicle crash without traumatic brain injury. Blood samples were obtained in all patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP-BDP (nanograms/milliliter). Results Of the 307 patients enrolled, 108 were patients with traumatic brain injury (97 with GCS score 13 to 15 and 11 with GCS score 9 to 12) and 199 were controls (176 normal controls and 16 motor vehicle crash controls and 7 orthopedic controls). Receiver operating characteristic curves demonstrated that early GFAP-BDP levels were able to distinguish patients with traumatic brain injury from uninjured controls with an area under the curve of 0.90 (95% confidence interval [CI] 0.86 to 0.94) and differentiated traumatic brain injury with a GCS score of 15 with an area under the curve of 0.88 (95% CI 0.82 to 0.93). Thirty-two patients with traumatic brain injury (30%) had lesions on CT. The area under these curves for discriminating patients with CT lesions versus those without CT lesions was 0.79 (95% CI 0.69 to 0.89). Moreover, the receiver operating characteristic curve for distinguishing neurosurgical intervention from no neurosurgical intervention yielded an area under the curve of 0.87 (95% CI 0.77 to 0.96). Conclusion GFAP-BDP is detectable in serum within an hour of injury and is associated with measures of injury severity, including the GCS score, CT lesions, and neurosurgical intervention. Further study is required to validate these findings before clinical application.

Background: Malfunctioning or dislodged gastrostomy tubes (G-tubes) often require urgent replacement and reinsertion in the Emergency Department (ED). Few data exist regarding the best technique for bedside catheter replacement and verification, and individual operator preferences vary. Although a few reports have described the use of ultrasound guidance during the initial percutaneous insertion, no data are available concerning its role during subsequent G-tube replacements. Objective: We sought to investigate the utility of bedside ultrasonography during G-tube replacements in the ED. Methods: This was a prospective pilot study conducted at a Level 1 Trauma Center with an annual census of 90,000 patients. Seven adults and three children with malfunctioning G-tubes were enrolled. Three tubes were cracked and leaking, and seven tubes had been dislodged. Under ultrasound, a new G-tube was inserted through the previously fashioned tract. After insertion, color Doppler was applied over the catheter tip to enhance visualization during gentle tube oscillation. Results: Ultrasound successfully visualized G-tube replacement in all 10 patients. Application of color Doppler over the G-tube tip during catheter oscillation enhanced placement confirmation. Sonographic findings were corroborated with gastric content aspiration, contrast-enhanced radiographs, and successful use of the new G-tubes. No false tracts were identified during ultrasound-guided insertion, post-procedure sonographic confirmation, or subsequent radiographs. Conclusion: The improper replacement of a G-tube can lead to devastating consequences. Verifying appropriate placement through aspirate evaluation can be misleading, and post-procedure radiographs increase radiation exposure and ED wait times. Bedside ultrasonography can be used to guide catheter insertion while providing a safe and quick adjunct to confirm proper G-tube placement.

This document presents the consensus of a group of international investigators who met to establish guidelines for the uniform reporting of data from studies of drowning incidents. The consensus process consisted of formal discussions at 3 international meetings as well as expert review, endorsements from multiple organizations, and invited recommendations from other interested parties. The concept of using consensus workshops to formulate guidelines is not new. Similar consensus guidelines for reporting surveillance and resuscitation research have been developed for both adult and pediatric cardiac arrest.1–3 The principal purpose of the recommendations in this advisory is to establish consistency in the reporting of drowning-related studies, both in terms of nomenclature and guidelines for reporting data. These recommendations are intended to improve the clarity of scientific communication and the comparability of scientific investigations. Improved clarity and comparability of future scientific reports will advance the clinical and epidemiological knowledge base. In turn, such studies can help identify appropriate prevention strategies as well as the best treatment for victims of drowning and can ultimately save lives. Laboratory and clinical investigators from many different specialties contribute to the multidisciplinary knowledge base of injury prevention and resuscitation science. Although diversity can be a strength, it can also be an obstacle because of the lack of a common language and communication between investigators from different backgrounds. In response to these problems, in June 1990 an international group of scientists concerned with research involving out-of-hospital cardiac arrest met at the Utstein Abbey in Stavanger, Norway. Participants discussed the lack of standardized nomenclature and definitions as a key problem in research reports. A second meeting, the Utstein Consensus Conference, was held in December 1990 in Brighton, England. Recommendations from this follow-up conference were published simultaneously in American and European journals.4,5 The report included uniform definitions, terminology, and …