Search

Influenza and respiratory syncytial virus (RSV) are associated with substantial morbidity and mortality in the United States. We assessed risk factors for severe disease and medical resource utilization (MRU) among US adults hospitalized with influenza or RSV in the Hospitalized Acute Respiratory Tract Infection (HARTI) study.HARTI was a prospective global (40 centers, 12 countries) epidemiological study of adults hospitalized with acute respiratory tract infections conducted across the 2017-2019 epidemic seasons. Patients with confirmed influenza or RSV were followed up to 3 months post-discharge. Baseline characteristics, prevalence of core risk factors (CRFs) for severe disease (age ≥65 years, chronic heart or renal disease, chronic obstructive pulmonary disease, or asthma), and MRU were summarized descriptively.The US cohort included 280 influenza-positive and 120 RSV-positive patients. RSV patients were older (mean: 63.1 vs. 59.7 years) and a higher proportion had CRFs (87.5% vs. 81.4%). Among those with CRFs (influenza, n = 153; RSV, n = 99), RSV patients required longer hospitalizations (median length of stay: 4.5 days) and a greater proportion (79.8%) required oxygen supplementation during hospitalization compared with influenza patients (4.0 days and 59.5%, respectively). At 3 months post-discharge, a greater proportion of RSV patients with CRFs reported use of antibiotics, antitussives, bronchodilators, and inhaled and systemic steroids versus those with influenza and CRFs. Many patients with CRFs reported hospital readmission at 3 months post-discharge (RSV: 13.4%; influenza: 11.9%).MRU during and post-hospitalization due to RSV in adults is similar to or greater than that of influenza. Enhanced RSV surveillance and preventive and therapeutic interventions are needed.

BackgroundmicroMend, a novel microstaple skin closure device, may be able to close simple lacerations. This study aimed to evaluate the feasibility and acceptability of using microMend to close these wounds in the ED.MethodsThis was an open-label, single-arm clinical study conducted at two EDs within a large urban academic medical centre. Wounds closed with microMend underwent assessments performed at days 0, 7, 30 and 90. Photographs of treated wounds were rated by two plastic surgeons using a 100 mm visual analogue scale (VAS) and a wound evaluation scale (WES), which has a best possible score of 6. Participants rated pain during application and both participants and providers rated their satisfaction with the device.ResultsThirty-one participants were enrolled in the study: 48% were female and the mean age of participants was 45.6 (95% CI 39.1 to 52.1). The mean wound length was 2.35 cm (95% CI 1.77 to 2.92), with a range of 1–10 cm. Mean VAS and WES scores at day 90 as evaluated by two plastic surgeons were 84.1 mm (95% CI 80.2 to 87.9) and 4.91 (95% CI 4.54 to 5.29), respectively. The mean pain score with application of the devices was 7.28 mm (95% CI 2.88 to 11.68) on a scale of 0–100 mm using VAS. Local anaesthesia was used in 9 patients (29%, 95% CI 20.7 to 37.3) of participants (of whom 5 required deep sutures). Ninety per cent (90%) of participants rated their overall assessment of the device as excellent (74%) or good (16%) at day 90. There were no serious adverse events in any participants in the study.ConclusionmicroMend appears to be an acceptable alternative for closing skin lacerations in the ED, providing good cosmetic results, with high levels of satisfaction by patients and providers. Randomised trials are needed to compare microMend with other wound closure products.Trial registration numberNCT03830515.

Study objective Acute urticaria is a frequent presentation in emergency departments (EDs), urgent care centers, and other clinical arenas. Treatment options are limited if diphenhydramine is the only intravenous antihistamine offered because of its short duration of action and well-known adverse effects. We evaluate cetirizine injection, the first second-generation injectable antihistamine, for acute urticaria in this multicenter, randomized, noninferiority, phase 3 clinical trial. Methods Adult patients presenting to EDs and urgent care centers with acute urticaria requiring an intravenous antihistamine were randomized to either intravenous cetirizine 10 mg or intravenous diphenhydramine 50 mg. The primary endpoint was the 2-hour pruritus score change from baseline, with time spent in treatment center and rate of return to treatment centers as key secondary endpoints. Frequency of sedation and anticholinergic adverse effects were also recorded. Results Among 262 enrolled patients, the 2-hour pruritus score change from baseline for intravenous cetirizine was statistically noninferior to that for intravenous diphenhydramine (–1.6 versus –1.5; 95% confidence interval –0.1 to 0.3), and in favor of cetirizine. Treatment differences also favored cetirizine for mean time spent in treatment center (1.7 versus 2.1 hours; P=.005), return to treatment center (5.5% versus 14.1%; P=.02), lower change from baseline sedation score at 2 hours (0.1 versus 0.5; P=.03), and adverse event rate (3.9% versus 13.3%). Conclusion Intravenous cetirizine is an effective alternative to intravenous diphenhydramine for treating acute urticaria, with benefits of less sedation, fewer adverse events, shorter time spent in treatment center, and lower rates of revisit to treatment center.

Background: Acute carbon monoxide poisoning is a common environmental emergency worldwide. Treatment options are limited to normobaric oxygen therapy with a nonrebreather face mask or endotracheal ...

Anemia, defined as a low hemoglobin concentration, has a large impact on the health of the world’s population. We describe the use of a ubiquitous device, the smartphone, to predict hemoglobin concentration and screen for anemia. This was a prospective convenience sample study conducted in Emergency Department (ED) patients of an academic teaching hospital. In an algorithm derivation phase, images of both conjunctiva were obtained from 142 patients in Phase 1 using a smartphone. A region of interest targeting the palpebral conjunctiva was selected from each image. Image-based parameters were extracted and used in stepwise regression analyses to develop a prediction model of estimated hemoglobin (HBc). In Phase 2, a validation model was constructed using data from 202 new ED patients. The final model based on all 344 patients was tested for accuracy in anemia and transfusion thresholds. Hemoglobin concentration ranged from 4.7 to 19.6 g/dL (mean 12.5). In Phase 1, there was a significant association between HBc and laboratory-predicted hemoglobin (HBl) slope = 1.07 (CI = 0.98–1.15), p

Field hospitals have long been used to extend health care capabilities in times of crisis. In response to the pandemic and an anticipated surge in patients, Rhode Island Gov. Gina Raimondo announced a plan to create three field hospitals, or "alternate hospital sites" (AHS), totaling 1,000 beds, in order to expand the state's hospital capacity. Following China's Fangcang shelter hospital model, the Lifespan AHS (LAHS) planning group attempted to identify existing public venues that could support rapid conversion to a site for large numbers of patients at a reasonable cost. After discussions with many stakeholders - pharmacy, laboratory, healthcare providers, security, emergency medical services, and infection control - design and equipment recommendations were given to the architects during daily teleconferencing and site visits. Specific patient criteria for the LAHS were established, staffing was prioritized, and clinical protocols were designed to facilitate care. Simulations using 4 different scenarios were practiced in order to assure proper patient care and flow, pharmacy utilization, and staffing.

Background Nonspecific orbital inflammation (NSOI) is a rare idiopathic ocular pathology characterized by unilateral, painful orbital swelling without identifiable infectious or systemic disorders, which can be complicated by optic nerve compromise. Case Report A 50-year-old man presented to the Emergency Department with recurring, progressive painless left eye swelling, decreased visual acuity, and binocular diplopia in the absence of trauma, infection, or known malignancy. His physical examination was notable for left-sided decreased visual acuity, an afferent pupillary defect, severe left eye proptosis and chemosis, and restricted extraocular movements; his dilatated funduscopic examination was notable for ipsilateral retinal folds within the macula, concerning for a disruption between the sclera and the retina. Ocular examination of the right eye was unremarkable. Laboratory data were unrevealing. Gadolinium-enhanced magnetic resonance imaging showed marked thickening of the left extraocular muscles associated with proptosis, dense inflammatory infiltration of the orbital fat, and characteristics consistent with perineuritis. The patient was diagnosed with NSOI with optic neuritis and admitted for systemic steroid therapy; he was discharged on hospital day 2 after receiving high-dose intravenous (i.v.) methylprednisolone with significant improvement. Why Should an Emergency Physician Be Aware of This? NSOI is a rare and idiopathic ocular emergency, with clinical mimicry resembling a broad spectrum of systemic diseases such as malignancy, autoimmune diseases, endocrine disorders, and infection. Initial work-up for new-onset ocular proptosis should include comprehensive laboratory testing and gadolinium-enhanced magnetic resonance imaging. Timely evaluation by an ophthalmologist is crucial to assess for optic nerve involvement. Signs of optic nerve compromise include decreased visual acuity, afferent pupillary defect, or decreased color saturation. Patients with optic nerve compromise require admission for aggressive anti-inflammatory therapy with i.v. steroids in an attempt to reduce risk of long-term visual sequelae. Our case demonstrates a severe presentation of this disorder and exhibits remarkable visual recovery after 48 h of systemic i.v. steroid treatment.

INTRODUCTION: Non-invasive screening of carboxyhemoglobin saturation (SpCO) in the emergency department to detect occult exposure is increasingly common. The SpCO threshold to consider exposure in smokers is up to 9%. The literature supporting this cutoff is inadequate, and the impact of active smoking on SpCO saturation remains unclear. The primary objective was to characterize baseline SpCO in a cohort of smokers outdoors. Secondary objectives were to explore the impact of active smoking on SpCO and to compare SpCO between smokers and non-smokers. METHODS: This was a prospective cohort pilot study in two outdoor urban public areas in the USA, in a convenience sample of adult smokers. SpCO saturations were assessed non-invasively before, during, and 2 min after cigarette smoking with pulse CO-oximetry. Analyses included descriptive statistics, correlations, and a generalized estimating equation model. RESULTS: Eighty-five smokers had mean baseline SpCO of 2.7% (SD 2.6) and peak of 3.1% (SD 2.9), while 15 controls had SpCO 1.3% (SD 1.3). This was a significant difference. Time since last cigarette was associated with baseline SpCO, and active smoking increased mean SpCO. There was correlation among individual smokers’ SpCO levels before, during, and 2 min after smoking, indicating smokers tended to maintain their baseline SpCO level. CONCLUSIONS: This study is the first to measure SpCO during active smoking in an uncontrolled environment. It suggests 80% of smokers have SpCO ≤ 5%, but potentially lends support for the current 9% as a threshold, depending on clinical context.

WOS: 000482723700039 PubMed: 30896133 Background Aim: Many Syrian civil war refugees are housed in carefully designed camps, however 60% of all refugees in host countries reside outside of specifically designated camps. Turkey hosts the largest number of refugees displaced in the civil war of Syria. In the present study, we aimed to illustrate healthcare services provided to Syrian refugees in Turkey. Method: Data presented in this retrospective observational registry study was obtained from multiple sources including official websites and written communications contributed by Turkish Disaster and Emergency Management Agency(AFAD), Turkish Ministry of Health and Turkish Red Crescent as well as the United Nations High Commissioner for Refugees(UNHCR). The number of refugee camps, total number of refugees housed in these camps, the demographic characteristics of the refugees and a breakdown of social and healthcare services provided in the camps including the number of healthcare professionals serving in the refugee camps were analyzed. Results: According to data from UNHCR as of January 12, 2017, there are 4,904,021 registered refugees from Syria of which 2,854,968 (58.2%) are residing in Turkey. Organized health care services specifically for Syrian refugees in Turkey was first established in April 29, 2011 in Hatay. Preventative health services are also provided for Syrian refugees. Among refugees living in the camps 25% and 33% were not vaccinated for polio and measles respectively. The percentage of unvaccinated refugees living outside the camps were even higher for these viruses (45% for polio and 41% for measles). This poses a public health threat for the population where these refugees reside. Conclusion: One of the major concerns for countries hosting refugees from Syria is the introduction of infectious diseases. Of the major deficiencies in refugee health care has been preventative services. Within refugee camps, preventative services for pregnant woman, newborns and young children as well as family planning services are not at optimal levels. These services are even more restricted for refugees living outside of established camps. There have also been shortcomings in the care of the elderly and those with chronic health problems.

INTRODUCTION Effective resuscitation of out-of-hospital cardiac arrest (OHCA) patients is challenging. Alternative resuscitative approaches using electromechanical adjuncts may improve provider performance. Investigators applied simulation to study the effect of an experimental automation-assisted, goal-directed OHCA management protocol on EMS providers' resuscitation performance relative to standard protocols and equipment. METHODS Two-provider (emergency medical technicians (EMT)-B and EMT-I/C/P) teams were randomized to control or experimental group. Each team engaged in 3 simulations: baseline simulation (standard roles); repeat simulation (standard roles); and abbreviated repeat simulation (reversed roles, i.e., basic life support provider performing ALS tasks). Control teams used standard OHCA protocols and equipment (with high-performance cardiopulmonary resuscitation training intervention); for second and third simulations, experimental teams performed chest compression, defibrillation, airway, pulmonary ventilation, vascular access, medication, and transport tasks with goal-directed protocol and resuscitation-automating devices. Videorecorders and simulator logs collected resuscitation data. RESULTS Ten control and 10 experimental teams comprised 20 EMT-B's; 1 EMT-I, 8 EMT-C's, and 11 EMT-P's; study groups were not fully matched. Both groups suboptimally performed chest compressions and ventilations at baseline. For their second simulations, control teams performed similarly except for reduced on-scene time, and experimental teams improved their chest compressions (P=0.03), pulmonary ventilations (P

SUMMARY: Erik Noji, mentioned, tongue in cheek, Noah as the first disaster manager during a lecture in 2005. The canonical description of “The Genesis Flood” does describe Noah as a master planner and executer of an evacuation of biblical proportions. After gaining knowledge of a potential catastrophic disaster he planned and executed an evacuation to mitigate the effects of the “Genesis Flood” by building the Ark and organizing a mass exodus. He had to plan for food, water, shelter, medical care, waste disposal and other needs of all the evacuees. Throughout history, management of large disasters was conducted by the military. Indeed, the military still plays a large role in disaster response in many countries, particularly if the response is overseas and prolonged. The histories of emergency preparedness, disaster management and disaster medicine have coevolved and are inextricably intertwined. While disaster management in one form or another existed as long as people started living together in communities, the development of disaster medicine took off with the emergence of modern medicine. Similar to disaster management, disaster medicine also has roots in military organizations. Keywords: History, disaster, medicine

Introduction Protocolized automation of critical, labor-intensive tasks for out-of-hospital cardiac arrest (OHCA) resuscitation may decrease Emergency Medical Services (EMS) provider workload. A simulation-based assessment method incorporating objective and self-reported metrics was developed and used to quantify workloads associated with standard and experimental approaches to OHCA resuscitation. Methods Emergency Medical Services-Basic (EMT-B) and advanced life support (ALS) providers were randomized into two-provider mixed-level teams and fitted with heart rate (HR) monitors for continuous HR and energy expenditure (EE) monitoring. Subjects' resting salivary α-amylase (sAA) levels were measured along with Borg perceived exertion scores and multidimensional workload assessments (NASA-TLX). Each team engaged in the following three OHCA simulations: (1) baseline simulation in standard BLS/ALS roles; (2) repeat simulation in standard roles; and then (3) repeat simulation in reversed roles, ie, EMT-B provider performing ALS tasks. Control teams operated with standard state protocols and equipment; experimental teams used resuscitation-automating devices and accompanying goal-directed algorithmic protocol for simulations 2 and 3. Investigators video-recorded resuscitations and analyzed subjects' percent attained of maximal age-predicted HR (%mHR), EE, sAA, Borg, and NASA-TLX measurements. Results Ten control and ten experimental teams completed the study (20 EMT-Basic; 1 EMT-Intermediate, 8 EMT-Cardiac, 11 EMT-Paramedic). Median %mHR, EE, sAA, Borg, and NASA-TLX scores did not differ between groups at rest. Overall multivariate analyses of variance did not detect significant differences; univariate analyses of variance for changes in %mHR, Borg, and NASA-TLX from resting state detected significant differences across simulations (workload reductions in experimental groups for simulations 2 and 3). Conclusions A simulation-based OHCA resuscitation performance and workload assessment method compared protocolized automation-assisted resuscitation with standard response. During exploratory application of the assessment method, subjects using the experimental approach appeared to experience reduced levels of physical exertion and perceived workload than control subjects.

Objective: To measure unhealthy aerosol materials in an Emergency Department (ED) and identify their sources for mitigation efforts. Background: Based on pilot findings of elevated ED particulate matter (PM) levels, investigators hypothesized that unhealthy aerosol materials derive from exogenous (vehicular) sources at ambulance receiving entrances. Methods: The Aerosol Environmental Toxicity in Healthcare-related Exposure and Risk program was conducted as an observational study. Calibrated sensors monitored PM and toxic gases at Ambulance Triage Exterior (ATE), Ambulance Triage Desk (ATD), and control Public Triage Desk (PTD) on a 3/3/3-day cycle. Cassette sampling characterized PM; meteorological and ambulance traffic data were logged. Descriptive and multiple linear regression analyses assessed for interactions between aerosol material levels, location, temporal variables, ambulance activity, and meteorological factors. Results: Sensors acquired 93,682 PM0.3, 90,250 PM2.5, and 93,768 PM5 measurements over 366 days to generate a data set representing at least 85.6% of planned measurements. PM0.3, PM2.5, and PM5 mean counts were lowest in PTD; 56%, 224%, and 223% higher in ATD; and 996%, 200%, and 63% higher in ATE, respectively (all p < .001). Qualitative analyses showed similar PM compositions in ATD and ATE. On multiple linear regression analysis, PM0.3 counts correlated primarily with location; PM2.5 and PM5 counts correlated most strongly with location and ambulance presence. PM < 2.5 and toxic gas concentrations at ATD and PTD patient care areas did not exceed hazard levels; PM0.3 counts did not have formal safety thresholds for comparison. Conclusions: Higher levels of PM were linked with ED ambulance areas, although their health impact is unclear.

Objectives The aim of this study is to compare efficacy of loop drainage and standard incision & drainage (I&D) in adult patients with cutaneous abscess in the emergency department. Methods This study is an interventional, parallel group, randomized clinical trial. Adult patients with cutaneous abscess were randomized into loop drainage and standard I&D groups. The primary outcome was defined as change in diameter of abscess and cellulitis 7 days after procedure. Secondary outcome measures were pain intensity at the end of the procedure and procedure duration. Also patient satisfaction, need for antibiotics and repetitive drainage were recorded. Results A total of 46 patients were included in the study (23 in each group). Both groups had similar baseline characteristics. Median abscess diameters were 3.2 (1.9–4.0) cm and 3.0 (2.4–4.8) cm in loop drainage and I&D groups respectively. In the loop drainage group there was a − 0.6 cm (95% CI: − 1.7–0.5) difference in abscess diameter compared to the I&D group. There was also a reduction in cellulitis diameter (− 1.3 cm, 95% CI: − 3.4–0.8). No statistically significant difference was found between groups in patient satisfaction, use of antibiotics or need for repetitive drainage. Conclusion This preliminary study revealed that, loop drainage technique is similar to standard I&D technique in abscess resolution and complications. (Clinical Trials Registration ID: NCT02286479 )

SUMMARY Initial stage of a disaster is managed with existing resources. The following stages of disaster response often involve assistance from outside of the disaster zone. This may consist of mutual aid from neighboring communities for small-scale incidents but in major disasters, the response is from federal or international agencies or often both. Rapid needs assessment after an incident is a collaborative effort between responding agencies and local emergency preparedness and health authorities. Ideally, a team from responding agencies with intimate knowledge and experience regarding the capabilities and assets of the responding entity along with local authorities, with decision making capacity, who have knowledge of the community, the limitations of the responding agencies and can obtain near real-time information about the incident and subject matter experts (engineering, medical, law enforcement, etc.) comprise the needs assessment team.

Summary Background Mass gatherings present enormous challenges for emergency preparedness. Planners must anticipate and prepare for communicable and non-communicable disease outbreaks, illnesses, and injuries to participants, crowd control, and disaster responses to unforeseen natural or man-made threats. The Hajj, the largest annually recurring mass gathering event on earth. It attracts about 3 million pilgrims from over 180 countries who assemble in Mecca over a 1-week period. Methods A literature review was conducted using Medline and OVID, while searching for published data concerning human stampedes and crowd control measures implemented to prevent human stampedes. The review was further extended to include media reports and published numbers and reports about Hajj from the Saudi Arabian government, in both the English and Arabic languages. Results Because millions of pilgrims undertake their religious ritual within strict constraints in term of space and time; this rigour and strictness have led to a series of large crowd disasters over several years, thus putting pressure on the authorities. In the past few years, the government of Saudi Arabia have put an enormous effort to solve this difficulty using state of the art innovative scientific means. The use of crowd simulation models, assessment of the best ways of grouping and scheduling pilgrims, crowd management and control engineering technologies, luggage management, video monitoring, and changes in the construction of the transport system for the event. Conclusions A large gathering such as the Hajj still holds an increasing risk for future disasters. International collaboration and continued vigilance in planning efforts remains an integral part of these annual preparations. The development of educational campaigns for pilgrims regarding the possible dangers is also crucial. Lessons gleaned from experiences at the Hajj may influence planning for mass gatherings of any kind, worldwide.

Introduction Acute urticaria is the most common symptom of acute allergic reactions. Diphenhydramine injection, the only available H1-antihistamine injection, is a 1stgeneration antihistamine with many side effects including sedation, short duration, anticholinergic effect, drug-drug interactions. Cetirizine injection, the first innovation in the H1-antihistamine injection space since 1955, minimizes these problems. A phase 3 clinical trial using a newly developed IV cetirizine was compared to IV diphenhydramine in treatment of acute urticaria. Methods 262 adult patients with acute urticaria and in need of IV H1-antihistamine injections were randomized to either IV cetirizine or IV diphenhydramine. Primary efficacy was the “2-hour pruritus score change from baseline”. Key secondary endpoints were “time spent in treatment center” and “need to return to ED/clinic within 48 hours”. Patient sedation was scored at 1 hour, 2 hours, and discharge. Results The “2-hour pruritus score change from baseline” from IV cetirizine was demonstrated to be statistically non-inferior to IV diphenhydramine, and in favor of cetirizine. “Time spent in treatment center” was 2.07 hours in the diphenhydramine group and 1.71 hours in cetirizine (per protocol p=0.0024). “Return to ED/Clinic” was 14% in the diphenhydramine group and 5.5% in cetirizine (p=0.0232). Data also showed significantly less sedation in the cetirizine group at 1hr (p=0.0034), 2hr (p=0.0292), and at discharge (p=0.0443) compared to diphenhydramine. Conclusions IV cetirizine is an effective alternative to IV diphenhydramine in the treatment of acute urticaria with benefits of less sedation, less AE, earlier discharge, less symptom recurrence, and less return to treatment center.

Introduction:Carbon monoxide (CO) toxicity is a significant health problem. The use of non-invasive pulse CO-oximetry screening in the emergency department has demonstrated that the rapid screening of numerous individuals for CO toxicity is simple and capable of identifying occult cases of CO toxicity.Objective:The objective of this study was to extend the use of this handheld device to the prehospital arena, assess carboxyhemoglobin (SpCO) levels in emergency medical services (EMS) patients, and correlate these levels with clinical and demographic data.Methods:This was a retrospective, observational, chart review of adult patients transported to hospital emergency departments by urban fire department EMS ambulances during a six-week period. Each ambulance used a non-invasive pulse CO-oximeter (Rad-57, Masimo Inc.) to record patients' COHb concentrations (SpCO) along with the standard EMS assessment data. Spearman's Rank Correlation tests and Student's t-tests were used to analyze the data and calculate relationships between SpCO and other variables (age, gender, respiratory rate, heart rate, mean arterial pressure, and oxygen saturation measured by pulse oximetry).Results:A total of 36.4% of the patients transported during the study had SpCO documented. Of the 1,017 adults included in this group, 11 (1.1%) had an SpCO >15%. There was no correlation between SpCO and heart rate, ventilatory rate, mean arterial pressure, and oxygen saturation.Conclusions:Screening for CO toxicity in the EMS setting is possible, and may aid in the early detection and treatment of CO-poisoned patients.

We conducted a prospective multicenter, open-label, escalating dose-range trial to compare, across patients, single intranasal doses (2, 4, 6, 8, and 10 mg) of hydromorphone HCl in the treatment of acute trauma pain The main outcome measure of pain-intensity reduction was derived from serial Numerical Pain-Rating Scores and calculated as the summed pain-intensity difference over 3 hours (SPID 3). Nasal examinations, vital signs, and adverse events were reported as safety outcomes. The mean decrease in pain intensity from baseline to 30 minutes was 39 to 44% for the 4-, 6-, 8- and 10-mg doses (n = 19, 33, 28, and 19 per group) and only 24% reduction for the 2-mg dose (n = 14). SPID 3 for the 2-mg dose was 40 to 50% below all other doses. There were no clinically meaningful changes in vital signs or nasal examinations. Adverse events (nausea, vomiting, pruritis, oxygen desaturation, bad taste, dizziness) were of mild to moderate intensity, increased with dose, and expected, based on route of administration and opioid pharmacology. Intranasal hydromorphone provides a component of rapid pain relief in the care of emergency department patients suffering from acute trauma pain. Perspective This article presents a pilot dose-ranging study of intranasally administered hydromorphone, administered in the emergency department to patients suffering from acute trauma pain. This study demonstrates research success in this setting and noninjection-based delivery and certain doses of intranasal hydromorphone may be effective in treating acute trauma pain.

Anemia is a serious disorder which, as a result of antiquated invasive blood testing, is undiagnosed in millions of people in the U.S. As a result of the clinical need, many technological solutions have been proposed to measure total blood hemoglobin, and thus diagnose anemia, noninvasively. Because hemoglobin is the strongest chromophore in tissue, spectroscopic methods have been the most prevalently investigated. Difficulties in extracting a quantitative estimation of hemoglobin based on tissue absorption include variability in the absorption spectra of hemoglobin derivatives, interference from other tissue chromophores, and interpatient physiological variations affecting the effective optical path length of light propagating in tissue. In spite of these challenges, studies with a high degree of correlation between in vitro and in vivo measured total hemoglobin have been disclosed using variants of transmission and diffuse reflection spectroscopy in assorted physiological locations. A review of these technologies and the relevant advantages/disadvantages are presented here.

Noninvasive methods of body fluid chemical measurement have been expanding. New technologies are enabling the quantification of different compounds in the blood and interstitial tissues. One example of this is the pulse oximeter, which has facilitated the measurement of oxyhemoglobin rapidly and reliably without the requirement of blood-draws. The Masimo Rad-57 Pulse CO-Oximeter expanded the capabilities of pulse-oximetry to include measurements of carboxyhemoglobin and methemoglobin. This innovation has revolutionized the paradigm for detection of patients with CO poisoning. Previously, clinicians relied on historical information and patient signs and symptoms pointing to the possibility of CO exposure or toxicity. Only then would a blood test be ordered to measure carboxyhemoglobin levels. Since the presentation of CO poisoning is nonspecific and overlaps with many other conditions, and since the presence of environmental CO is often unknown, the detection of this condition was only possible in cases where the presence of CO was obvious or where the symptoms were severe. We now know, from studies conducted using the Rad-57, the only US FDA-approved device for noninvasive measurement of SpCO, that there are a significant number of patients who experience CO exposure but are nonsymptomatic. The Rad-57 provides a clinical justification for screening in the healthcare setting to identify patients with significant CO exposure who would otherwise be undetected.

Background: Anemia is an underdiagnosed, significant public health concern afflicting >2 billion people worldwide. The detrimental effects of tissue oxygen deficiency on the cardiovascular system and concurrent appearance of anemia with numerous high-risk disorders highlight the importance of clinical screening. Currently there is no universally accepted, clinically applicable, noninvasive hemoglobin/hematocrit screening tool. The need for such a device has prompted an investigation into a breadth of techniques. Methods: A synopsis of the literature and current directions of research in noninvasive total hemoglobin measurement was collected. Contributions highlighted in this review are limited to those studies conducted with a clinical aspect, and most include in vivo patient studies. Results: The review of potential techniques presented here includes optoacoustic spectroscopy, spectrophotometric imaging, diffuse reflectance spectroscopy, transcutaneous illumination, electrical admittance plethysmography, and photoplethysmography. The technological performance, relative benefits of each approach, potential instrumentation design considerations, and future directions are discussed in each subcategory. Conclusions: Many techniques reviewed here have shown excellent accuracy, sensitivity, and specificity in measuring hemoglobin/hematocrit, thus in the near future a new clinically viable tool for noninvasive hemoglobin/hematocrit monitoring will likely be widely used for patient care. Limiting factors in clinical adoption will likely involve technology integration into the current standard of care in each field routinely dealing with anemia.

Objectives: Carbon monoxide (CO) toxicity causes significant central nervous system and cardiac injury. Although the neurological damage caused by CO toxicity is extensively described, the mechanisms underlying myocardial insult are unclear. The authors used an externally perfused isolated rat heart model to examine the effects of a physiological saline solution (Krebs Henseleit HEPES, KHH) aerated with CO on cardiac function. Methods: Fifteen rats were equally divided into three groups: the control group (KHH + 100% O2), the nitrogen control group (KHH + 70% O2, 30% N2), and the CO group (KHH + 70% oxygen, 30% CO). Left ventricular peak systolic pressure (LVPsP), end diastolic pressure (LVEdP), and coronary perfusion pressure were measured while the isolated heart was paced and perfused on a modified Langendorf apparatus. Results: Left ventricular generated pressure (LVGP = LVPsP − LVEdP) decreased in the nitrogen control and CO groups compared to the control group. There was higher LVGP in the recovery phase between the nitrogen control group compared to the CO group. Both groups had increased lactic acid levels in the experimental phase. Conclusions: Carbon monoxide with hypoxia and hypoxemic hypoxia both result in similar depression of cardiac function. Hearts poisoned with CO with hypoxia do not recover function to the extent that hearts rendered hypoxic with nitrogen do when perfused with 100% oxygen after the insult. This suggests that CO causes direct myocardial toxicity distinct from the effects of hypoxia.

The objective of this study was to determine whether digital photography could be used to calculate hemoglobin. This prospective blinded study was conducted in a tertiary care Emergency Department (ED). A convenience sample of 65 patients provided consent; 44 patients were enrolled for formula derivation and 19 for prospective analysis. Hemoglobin concentration in blood was determined by a cell counter. Software was developed to predict the hemoglobin value based on a formula derived using the images and known hemoglobin values from a derivation set of patients. Pearson's rank order correlation between the calculated and measured hemoglobin was r(77) = 0.634, p < 0.01 for the derivation group and r(36) = 0.522, p < 0.01 for the evaluation group. It is possible to derive an objective method that correlates conjunctiva color with measured hemoglobin and, when applied prospectively, is able to predict hemoglobin concentration in ED patients. This technology has broad applications in regions with limited resources.

Objectives: Although road bicycle races have been held for more than a century, injury and illness patterns during multi-day bicycle events have not been widely studied. The aim of this study was to determine the incidence of injury and illness among riders and describe the medical care interventions provided to participants of cycling road races. Methods: A prospective observational study was conducted on the Presidential Cycling Tour of Turkey, which was held between April 26 and May 3, 2015. The race lasted 8days and covered 1258km of road. There were 166 elite cycling athletes representing 21 teams from various countries. Data collected pertaining to incidents involving injury or illness included the following: type of injury; anatomical location of injury; details of the medical encounter; location of the intervention; treatment provided; medication administered and disposition of the rider. An injury was defined as a physical complaint or observable damage to the body produced by the transfer of energy of the rider. An illness was defined as a physical complaint or presentation not related to injury. Results: The overall incidence (injury and illness) was 5.83 per 1000 cycling hours. (Injury incidence was 2.82 vs illness incidence of 3.01 per 1000hours cycling). A total of 31 incidents occurred. Of these, 15 were injuries, while 16 were complaints of a non-traumatic nature. A total of 43 interventions were made in the 15 cases of injury. The most commonly injured body regions were limbs; the majority of injuries involved the skin and soft tissue. The most common medical intervention was wound care (64% of all interventions). Two riders had to withdraw from the race, and one was hospitalized due to a traumatic pneumothorax. None of the non-traumatic cases resulted in withdrawal from the race. Conclusions: A broad spectrum of illness and injury occurs during elite multi-day road races, ranging from simple skin injuries to serious injuries requiring hospital admission. Most injuries and illnesses are minor; however, medical teams must be prepared to treat life-threatening trauma.

We investigated Turkish emergency physicians' opinions about the threat of smallpox, smallpox vaccination, and the treatment of patients with suspected smallpox, and sought to identify factors that affect willingness to receive smallpox vaccination. Anonymous surveys were sent by mail to university-affiliated Emergency Departments in Turkey. Ten of the 21 university-based Emergency Medicine programs participated in the study, and 125 physicians (48% of all emergency physicians in Turkey) completed the survey. The probability of a bioterror attack using smallpox within Turkish borders was viewed as none or mininal by 43.2% of participants. Only 22.4% of the participants stated that they would agree to be vaccinated. The only factor that affected the rate of participants' willingness to recive smallpox vaccination was the occurrence of a smallpox case within Turkish borders. Decisions about the treatment of patients with suspected smallpox are strongly influenced by whether or not the physician has been vaccinated against smallpox. At the time of the survey, even during the weeks leading up to and during the war in Iraq, Turkish emergency physicians' perceived risk of a bioterror attack using the smallpox virus was low. A significant number of Turkish emergency physicians were unwilling to participate in a hypothetical vaccination program. This study shows that the occurrence of a smallpox case within Turkish borders would significantly increase the willingness of emergency physicians to receive the smallpox vaccine. Decisions about treatment of patients with suspected smallpox are strongly influenced by whether or not the physician has been vaccinated against smallpox. (C) 2005 Elsevier Inc.

We investigated Turkish emergency physicians' views regarding family witnessed resuscitation (FWR) and to determine the current practice in Turkish academic emergency departments with regard to family members during resuscitation. A national cross-sectional, anonymous survey of emergency physicians working in academic emergency departments was conducted. Nineteen of the 23 university-based emergency medicine programs participated in the study. Two hundred and thirty-nine physicians completed the survey. Of the respondents, 83% did not endorse FWR. The most common reasons for not endorsing FWR was reported as higher stress levels of the resuscitation team and fear of causing physiological trauma to family members. Previous experience, previous knowledge in FWR, higher level of training and the acceptance of FWR in the institution where the participant works were associated with higher rates of FWR endorsement for this practice among emergency physicians.

Objective: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Setting: Level 1 trauma center and academic emergency medicine training program. Participants: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. Intervention: : ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC®) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Design: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. Results: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. Conclusion: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

Study objective: We describe and analyze a recent rapid deployment of disaster medical assistance teams and other government agencies to provide medical screening and anthrax prophylaxis to New York City US Postal Service employees potentially exposed to letters contaminated with anthrax spores. Methods: A description of the response effort is presented. Data were collected on standardized forms and included the numbers of postal employees screened and offered antibiotic prophylaxis, as well as the numbers of patients seen per worker hour by various medical professionals. Results: One hundred members of 5 disaster medical assistance teams and other health professionals were deployed to New York City within 18 hours of activation. Over a 68-hour period, 7,076 patients were evaluated, representing all postal employees in the 6 major postal facilities in New York believed to be at risk for anthrax exposure. Of the total, 2,452 patients were seen during the first 24 hours, 3,875 during the second 24 hours, and the remaining 749 during the last 20 hours of operations. An average of 161 employees were screened per hour. The antibiotic most commonly dispensed was ciprofloxacin, followed by doxycycline and amoxicillin. Conclusion: The deployment of disaster medical assistance teams and other agencies to New York City to provide prophylaxis against inhalation anthrax to US Postal Service employees provides lessons for a rapid, efficient, and effective response to acts of bioterrorism. This deployment might also serve as a scaleable model for future events requiring medical prophylaxis. [ Ann Emerg Med. 2003;41:441-446.]

Much has been written regarding the topic of the acute scrotum, and it continues to be a focus of research and subject of debate. An embarrassing subject to discuss with patients, and often underemphasized by caretakers, the male with acute scrotal, groin, or lower abdominal pain requires prompt, accurate diagnosis and management. Although a broad scope of etiologies manifest as an acute scrotum, testicular torsion, testicular and epididymal appendage torsion and epididymitis account for the majority of presentations. We will attempt to examine the specific epidemiological, anatomic, microbiologic, pathophysiologic, and management considerations for each of the aforementioned conditions, while also discussing more rare, life-threatening presentations of the acute scrotum. Painless scrotal masses will also be discussed.

Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.

Ventricular tachycardia is a dangerous dysrhythmia most commonly encountered in adult patients with heart disease. It is uncommon for a previously healthy child to present to the emergency department with hemodynamically stable ventricular tachycardia. The diagnosis and management of this dysrhythmia may pose a significant challenge to the emergency physician. We present the case of a previously healthy child with a structurally normal heart who had ventricular tachycardia for a prolonged period. Common causes of childhood tachycardia and options for treatment of stable and unstable patients are discussed.

Objective Describe hiking habits in a heavily used wilderness area to better target injury prevention and reduce search-and-rescue events. Methods A cross-sectional, convenience survey was conducted at 3 trailheads in the White Mountain National Forest of New Hampshire during summer 2011. The study group consisted of hikers who consented to a questionnaire before their trip that assessed demographics, experience, hiking gear, pretrip planning, and communication devices. Results A total of 199 hikers were surveyed. The most common age group was 20 to 29 years at 29.2% (n = 195). The most common hike was less than 12 hours at 78.5% (n = 191). All 10 items deemed essential were carried by 17.8% (n = 197) of hikers. The most common omission reason was "short trip" at 32.2% (n = 162). Defined as greater than 7 items, the 50- to 59-year-old age group was the most prepared at 56.9% (n = 51). Hiker preparedness increased with experience and fitness levels. Hikers planning trips of less than 12 hours were less prepared compared with hikers planning longer trips, at 39.3% (n = 150) and 48.8% (n = 41), respectively. GPS devices were carried by 122 of 193 hikers. Phone GPS users were less prepared than GPS-only device users at 35.8% (34 of 95) and 55.6% (15 of 27), respectively. Conclusions One factor that may help reduce rescues is better-prepared individuals able to avoid emergency medical services activation. Most neglect of preparation results from hikers perceiving short trips as less risky. The groups most often underprepared tend to be younger, less fit, and inexperienced. Therefore, education should target younger groups and stress that all hikes, regardless of duration, carry an inherent risk.

During the influenza season patients are labeled as having an influenza-like illness (ILI) which may be either a viral or bacterial infection. We hypothesize that C-reactive protein (CRP) levels among patients with ILI diagnosed with a bacterial infection will be higher than patients diagnosed with an influenza or another viral infection.We enrolled a convenience sample of adults with ILI presenting to an urban academic emergency department from October to March during the 2008 to 2011 influenza seasons. Subjects had nasal aspirates for viral testing, and serum CRP. Bacterial infection was determined by positive blood cultures, radiographic evidence of pneumonia, or a discharge diagnosis of bacterial infection. Receiver operating characteristic curve, analysis of variance, and Student t test were used to analyze results.Over 3 influenza seasons there were 131 total patients analyzed (48 influenza infection, 42 other viral infection and 41 bacterial infection). CRP values were 25.65 mg/L (95% CI, 18.88-32.41) for influenza, 18.73 mg/L (95% CI, 12.97-24.49) for viral and 135.96 mg/L (95% CI, 99.38-172.54) for bacterial. There was a significant difference between the bacterial group, and both the influenza and other viral infection groups (P.001). The receiver operating characteristic curve for CRP as a determinant of bacterial infection had an area under the curve of 0.978, whereby a CRP value of20 had a sensitivity of 100% and80 had a specificity of 100%.C-reactive protein is both a sensitive and specific marker for bacterial infection in patients presenting with ILI during the influenza season.