Notes

Treatments for Main Poststroke Ache: Thorough Report on Randomized Governed Studies.
Shock from medical and traumatic conditions can result in organ injury and death. Limited data describe out-of-hospital treatment of shock. We sought to characterize adult out-of-hospital shock care in a national emergency medical services (EMS) cohort.

This cross-sectional study used 2018 data from ESO, Inc. (Austin, TX), a national EMS electronic health record system, containing data from 1289 EMS agencies in the United States. We included adult (age ≥18 years) non-cardiac arrest patients with shock, defined as initial systolic blood pressure ≤80 mm Hg. We compared patient demographics, clinical characteristics, and response (defined as systolic blood pressure increase) between medical and traumatic shock patients, looking at systolic blood pressure trends over the first 90 minutes of care.

Among 6,156,895 adult 911 responses, shock was present in 62,867 (1.02%; 95% confidence interval [CI] = 1.01%-1.03%); 54,239 (86.3%) medical and 5978 (9.5%) traumatic, and 2650 unknown. Medical was more common than traumatic shock in women and older patients. The most common injuries associated with traumatic shock were falls (37.6%) and motor vehicle crashes (18.7%). Mean initial and final medical systolic blood pressure were 71 ± 10 mm Hg and 99 ± 24 mm Hg. Systolic blood pressure increased in 88.8% and decreased or did not change in 11.0%. Mean initial and final trauma systolic blood pressure were 71 ± 13 mm Hg and 105 ± 28 mm Hg; systolic blood pressure increased in 90.4% and decreased/did not change in 9.6%. On fractional polynomial modeling, systolic blood pressure changes were greater and faster for trauma than medical shock.

In this national series, 1 of every 100 EMS encounters involved shock. These findings highlight the current course and care of shock in the out-of-hospital setting.
In this national series, 1 of every 100 EMS encounters involved shock. These findings highlight the current course and care of shock in the out-of-hospital setting.
Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.

Review article.

Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reporterts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.
Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.Hip dislocation is a common complication after total hip arthroplasty surgery. see more Newer prosthetic implants aim to reduce the risk of dislocation. The new dual mobility implant has a unique design that may result in intra-prosthetic dislocation. We report a case of a recurrently missed iatrogenic intra-prosthetic dislocation following closed reduction efforts in the emergency department (ED). Emergency physicians must be aware of the design, pitfalls, and management of this new prosthetic hip design.
A female patient known to have schizoaffective disorder self-presented to an emergency department in a state of acute agitation and paranoia shortly after a 35-day inpatient stay at a psychiatric facility.

The patient exhibited no signs or complaints of dyspnea or hypoxia, but later collapsed and became hypoxic after sleeping comfortably with sedation for 12h in the psychiatric unit. She was intubated and a computed tomography angiogram revealed bilateral lobar pulmonary emboli and right heart strain.

Psychiatric hospitalizations, medications, diagnoses and relevant sequelae increase venous thromboembolism risk more than many realize.
Psychiatric hospitalizations, medications, diagnoses and relevant sequelae increase venous thromboembolism risk more than many realize.Emergency physicians face real-time ethical dilemmas that may occur at any hour of the day or night. Hospital ethics committees and ethics consultation services are not always able to provide immediate responses to emergency physicians' consultation requests. When faced with an emergent dilemma, emergency physicians sometimes rely on risk management or hospital counsel to answer legal questions, but may be better served by real-time ethics consultation. When other resources are not immediately available, emergency physicians should feel confident in making timely decisions, guided by basic principles of medical ethics. We make the following recommendations (1) availability of a member of the hospital ethics committee to provide in-person or telephonic consultation concurrent with patient care; (2) appointment to the hospital ethics committee of an emergency physician who is familiar with bioethical principles and is available for consultation when other ethics consultants are not; and (3) development of educational tools by professional societies or similar organizations to assist emergency physicians in making reasoned and defensible clinical ethics decisions.
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