Academic Emergency Medicine (ACAD EMERG MED)

Publisher: Society for Academic Emergency Medicine (U.S.), Wiley

Journal description

AEM is a monthly peer-reviewed journal that publishes material relevant to the practice, education, and investigation of emergency medicine, and reaches a wide audience of emergency care practitioners and educators. Each issue contains a broad range of topics relevant to the improvement of emergency, urgent, or critical care of the acutely ill or injured patient. Regular features include original research, preliminary reports, education & practice, annotated literature.

Current impact factor: 2.01

Impact Factor Rankings

2016 Impact Factor Available summer 2017
2014 / 2015 Impact Factor 2.006
2013 Impact Factor 2.198
2012 Impact Factor 1.757
2011 Impact Factor 1.861
2010 Impact Factor 2.197
2009 Impact Factor 2.478
2008 Impact Factor 2.46
2007 Impact Factor 1.99
2006 Impact Factor 1.741
2005 Impact Factor 1.789
2004 Impact Factor 1.898
2003 Impact Factor 1.844
2002 Impact Factor 1.535
2001 Impact Factor 1.144
2000 Impact Factor 1.419
1999 Impact Factor 1.748
1998 Impact Factor 1.079
1997 Impact Factor 1.042

Impact factor over time

Impact factor
Year

Additional details

5-year impact 2.28
Cited half-life 7.70
Immediacy index 0.72
Eigenfactor 0.01
Article influence 0.86
Website Academic Emergency Medicine website
Other titles Academic emergency medicine
ISSN 1069-6563
OCLC 28131897
Material type Periodical, Internet resource
Document type Journal / Magazine / Newspaper, Internet Resource

Publisher details

Wiley

  • Pre-print
    • Author can archive a pre-print version
  • Post-print
    • Author cannot archive a post-print version
  • Restrictions
    • 12 months embargo
  • Conditions
    • Some journals have separate policies, please check with each journal directly
    • On author's personal website, institutional repositories, arXiv, AgEcon, PhilPapers, PubMed Central, RePEc or Social Science Research Network
    • Author's pre-print may not be updated with Publisher's Version/PDF
    • Author's pre-print must acknowledge acceptance for publication
    • Non-Commercial
    • Publisher's version/PDF cannot be used
    • Publisher source must be acknowledged with citation
    • Must link to publisher version with set statement (see policy)
    • If OnlineOpen is available, BBSRC, EPSRC, MRC, NERC and STFC authors, may self-archive after 12 months
    • If OnlineOpen is available, AHRC and ESRC authors, may self-archive after 24 months
    • Publisher last contacted on 07/08/2014
    • This policy is an exception to the default policies of 'Wiley'
  • Classification
    yellow

Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and non-violent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering and outcomes. Methods: This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale (GCS) score ≤ 8, injured by one of 4 primary injury mechanisms (firearm, stabbing, assault and MVC) who were transported by EMS to a Level I or II trauma center in 10 regions of the U.S. and Canada from January 1, 2010 through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes and spatial clustering. Results: There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%) and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included: 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters. Conclusions: Severe firearm events tend to occur within the patient's own neighborhood, often at home and generally outside of specific geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Shortness of breath is a common presenting complaint in the emergency department (ED) with a wide differential diagnosis that includes acute heart failure (AHF), exacerbation of chronic obstructive pulmonary disease (COPD), pneumonia, and pulmonary embolism. The findings for these etiologies of dyspnea overlap, particularly in aging adults with significant co-morbidities. Delays in the diagnosis and treatment of AHF worsen prognosis and increase healthcare costs. Emergency physicians play a key role in diagnosing AHF, assessing symptom severity, choosing initial management strategies, and determining disposition from the ED. (5) Understanding the benefits and pitfalls of using history, physical exam, routine labs, x-ray imaging, and bedside sonography is essential. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To determine the effect of apneic oxygenation (AP OX) on first pass success without hypoxemia (FPS-H) in adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods: Continuous quality improvement (CQI) data were prospectively collected on all patients intubated in an academic ED from July 1, 2013 to June 30, 2015. During this period the use of AP OX was introduced and encouraged for all patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data form which included information on patient, operator and intubation characteristics. Adult patients 18 years of age or greater who underwent RSI in the ED by emergency medicine residents were included in the analysis. The primary outcome was FPS-H, which was defined as successful tracheal intubation on a single laryngoscope insertion without oxygen saturation falling below 90%. A multivariate logistic regression analysis was performed to determine the effect of AP OX on FPS-H. Results: During the two-year study period, 635 patients met inclusion criteria. Of these, 380 (59.8%) had AP OX utilized and 255 (40.2%) had NO AP OX utilized. In the AP OX cohort the FPS-H was 312/380 (82.1%) and in the NO AP OX cohort the FPS-H was 176/255 (69.0%) (difference 13.1%; 95% CI 6.2% to 19.9%). In the multivariate logistic regression analysis, the use of AP OX was associated with an increased odds of FPS-H (adjusted OR 2.2; 95% CI: 1.5 to 3.3). Conclusion: The use of AP OX during the RSI of adult patients in the ED was associated with a significant increase in FPS-H. These results suggest that the use of AP OX has the potential to increase the safety of RSI in the ED by reducing the number of attempts and incidence of hypoxemia. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: The General Internal Medicine (GIM) Care Transformation Initiative implemented at 1 of 4 teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the Emergency Department (ED) is unclear. Methods: Controlled before-after study of ED length of stay (LOS) and crowding metrics for the intervention site (n=108,951 visits) compared to the three other teaching hospitals (controls, n=300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics. Results: The GIM Care Transformation was associated with an additional 2.8 hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3 hour decline (from 30.6 hours to 21.3 hours) seen in the 3 control EDs for GIM patients who were hospitalized (p<0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p<0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p<0.001) at the intervention hospital pre vs. post (p=0.04 for the 15 minute additional reduction, p<0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences. Conclusion: Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: To determine whether guideline-concordant emergency department (ED) management of acute asthma is associated with a shorter hospital length-of-stay (LOS) among patients hospitalized for asthma. Methods: A multicenter chart review study of patients aged 2-54 years who were hospitalized for acute asthma at one of the 25 US hospitals during 2012-2013. Based on level-A recommendations from national asthma guidelines, we derived 4 process measures of ED treatment before hospitalization: inhaled β-agonists, inhaled anticholinergic agents, systemic corticosteroids, and lack of methylxanthines. The outcome measure was hospital LOS. Results: Among 854 ED patients subsequently hospitalized for acute asthma, 532 patients (62%) received care perfectly concordant with the 4 process measures in the ED. Overall, the median hospital LOS was 2 days (IQR, 1-3 days). In the multivariable negative binomial model, patients who received perfectly-concordant ED asthma care had a significantly shorter hospital LOS (-17%; 95%CI, -27% to -5%; P=0.006), compared to other patients. In the mediation analysis, the direct effect of guideline-concordant ED asthma care on hospital LOS was similar to that of primary analysis (-16%; 95%CI, -27% to -5%; P=0.005). By contrast, the indirect effect mediated by quality of inpatient asthma care was not significant, indicating that the effect of ED asthma care on hospital LOS was mediated through pathways other than quality of inpatient care. Conclusion: In this multicenter observational study, patients who received perfectly concordant asthma care in the ED had a shorter hospital LOS. Our findings encourage further adoption of guideline-recommended emergency asthma care to improve patient outcomes. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Vancomycin loading doses are recommended, however, the risk of nephrotoxicity with these doses is unknown. The primary objective of this study was to compare nephrotoxicity in emergency department (ED) sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (≤20 mg/kg). Methods: A retrospective cohort study was performed in three academic EDs. Inclusion criteria: age ≥ 18 years, IV vancomycin order, and hospital admission. Exclusion criteria: no documented weight, hemodialysis-dependent, inadequate serum creatinine (SCr) values for the measured outcome. Analyses compared the incidence of nephrotoxicity for patients who received vancomycin at high dose (>20 mg/kg) vs. low dose (≤20 mg/kg). Results: A total of 2,131 consecutive patients prescribed vancomycin over 6 months were identified. Of these, 1,330 patients had three SCr values assessed for the primary outcome. High dose initial vancomycin was associated with a significantly lower rate of nephrotoxicity (5.8% vs 11.1%). After adjusting for age, gender, and initial SCr, the risk of high dose vancomycin compared to low dose was decreased for the development of nephrotoxicity (RR=0.60; 95% CI: 0.44, 0.82). Conclusion: Initial dosing of vancomycin >20 mg/kg, was not associated with an increased rate of nephrotoxicity compared with lower doses. Findings from this study support compliance with initial weight-based vancomycin loading doses. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: We sought to determine the extent of variation in treatment of children with anaphylaxis. Methods: We identified children 1 month to 18 years of age presenting with a primary diagnosis of anaphylaxis to one of the 35 pediatric hospitals included in the Pediatric Health Information System between January 1, 2009 and September 30, 2013. We evaluated the variation in use of beta-2 agonists, glucocorticoids, histamine-1 antagonists, histamine-2 antagonists, inhaled epinephrine, intravenous fluids, and oxygen. We assessed whether variation exists in the rates of hospitalization and 3-day emergency department revisits, and whether a temporal trend exists in the ED visit rate for anaphylaxis. Results: Among 10351 children with anaphylaxis, the hospital-level median use of common anaphylaxis therapies varied for β2 agonists (22%, interquartile range [IQR] 16-26), glucocorticoids (71%, IQR 65-76), H1 blockers (60%, IQR 57-65), H2 blockers (53%, IQR 36-64), inhaled epinephrine (2.2%, IQR 1.3-3.5), intravenous fluids (26%, IQR 13-41), and oxygen (2.6%, IQR 0.8-4.1). Hospitalization rates ranged from 12% to 95%, with a median rate of 41%. Anaphylaxis diagnoses rose from 5.7 to 11.7 patients per 10,000 ED visits between 2009 and 2013 (p < 0.001 for trend). Conclusions: There is substantial variability in the use of common therapies and hospitalization rates for children cared for in U.S. children's hospitals. Additionally, emergency department visits for children with anaphylaxis are increasing at U.S. children's hospitals. These findings highlight the need for research defining optimal care for anaphylaxis. This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Headache is a very common emergency department (ED) chief complaint, representing about 2.8% of all visits in the United States (U.S.).1 Sudden onset, severe headache often warrants evaluation for etiologies with unacceptably high morbidity and lethality, including subarachnoid hemorrhage (SAH). Noncontrast head computed tomography (CT) as soon as possible after the onset of headache is the initial SAH diagnostic test of choice, but older studies indicate that up to one-in-three SAH patients were misdiagnosed during the initial ED encounter with subsequent treatment delays producing less optimal patient outcomes due to failure to perform or appropriately interpret lumbar puncture (LP) results in headache patients with a non-diagnostic CT.2 Early generation CT studies reported inadequate sensitivities for the diagnosis of SAH so post-imaging LP was the standard work-up to adequately exclude SAH.3 The American College of Emergency Physicians (ACEP) Clinical Policy Statement for the evaluation of adult headache patients currently provide a Level B recommendation supporting LP following non-diagnostic non-contrast head CT to rule out SAH.4 Recent studies using newer generation CT scanners demonstrate significantly improved sensitivities for detecting SAH if performed within six hours, rendering providers and clinical educators to question the benefit for LP in this population.5 This article is protected by copyright. All rights reserved.
    No preview · Article · Feb 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Delayed diagnosis of Kawasaki disease (KD) may lead to serious cardiac complications. We sought to create and test the performance of a natural language processing (NLP) tool, the KD-NLP, in the identification of emergency department (ED) patients for whom the diagnosis of KD should be considered. Methods: We developed an NLP tool that recognizes the KD diagnostic criteria based on standard clinical terms and medical word usage using 22 pediatric ED notes augmented by Unified Medical Language System (UMLS) vocabulary. With high suspicion for KD defined as fever and ≥3 KD clinical signs, KD-NLP was applied to 253 ED notes from children ultimately diagnosed with either KD or another febrile illness. We evaluated KD-NLP performance against ED notes manually reviewed by clinicians and compared the results to a simple keyword search. Results: KD-NLP identified high suspicion patients with a sensitivity of 93.6% and specificity of 77.5% as compared to notes manually reviewed by clinicians. The tool outperformed a simple keyword search (sensitivity 41.0%; specificity 76.3%). Conclusions: KD-NLP showed comparable performance to clinician manual chart review for identification of pediatric ED patients with a high suspicion for KD. This tool could be incorporated into the ED electronic health record system to alert providers to consider the diagnosis of KD. KD-NLP could serve as a model for decision support for other conditions in the ED. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Pneumonia severity tools were primarily developed in cohorts of hospitalized patients, limiting their applicability to the emergency department (ED). We describe current community ED admission practices and examine the accuracy of the CURB-65 to predict 30-day mortality for patients, either discharged or admitted with, community acquired pneumonia (CAP). Methods: A retrospective, observational study of adult CAP encounters in 14 community EDs within an integrated health care system. We calculated CURB-65 scores for all encounters and described the use of hospitalization, stratified by each score (0-5). We then used each score as a cut-off to calculate sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratios and negative likelihood ratios for predicting 30-day mortality. Results: The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 for predicting 30-day mortality in the full sample was 0.761 (95% CI, 0.747-0.774). The C-statistic was 0.864 (95% CI, 0.821-0.906) among patients discharged from the ED compared with 0.689 (95% CI, 0.672-0.705) among patients who were admitted. Among all ED encounters a CURB-65 threshold ≥1 was 92.8% sensitive and 38.0% specific for predicting mortality, with a 99.9% NPV. Among all encounters, 62.5% were admitted, including 36.2% of those at lowest risk (CURB-65=0). Conclusion: CURB-65 had very good accuracy for predicting 30-day mortality among patients discharged from the ED. This severity tool may help ED providers risk stratify patients to assist with disposition decisions and identify unwarranted variation in patient care. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: o describe the frequency of and factors associated with prolonged peripheral intravenous catheter (PIV) insertion in the resuscitation area of a pediatric emergency department (PED). Methods: Video-based study of a consecutive sample of non-trauma patients undergoing PIV insertion in the resuscitation area of a PED. Pre-existing videos were the main data source. The primary outcome was patients with prolonged duration of PIV insertion (> 90 seconds from start of first attempt to successful flush/blood draw). Logistic regression identified variables independently associated with prolonged PIV insertion. Results: 151 consecutive non-trauma patients underwent PIV insertion during a 2.5 month period. Sixty-nine patients (46%) had prolonged PIV insertion, including 14 for whom PED providers failed to insert PIVs. For patients with successful PIV insertion by PED providers, median duration was 48 sec (interquartile range 23, 295). Vascular access was ultimately achieved for 13 patients (93%) with initial insertion failure by the PED team (10 non-PED personnel, 3 intraosseous lines), with a median duration of 26.7 min (IQR 19.9, 34.2). Age ≤ 2 years (ORadj 6.9, 95% CI 2.9, 16.1) and musculoskeletal contractures (ORadj , 5.3, 95% CI 1.6, 17.2) were independently associated with prolonged PIV insertion. Conclusion: Prolonged PIV insertion is common in a PED resuscitation area. When PED providers could not insert a PIV, time to insertion was very long. Young patients and those with contractures were at particular risk for prolonged and failed PIV placement. When emergent vascular access is required, alternative approaches should be considered early for these patients. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: The Clinical and Translational Science Award (CTSA) program aims to strengthen and support translational research by accelerating the process of translating laboratory discoveries into treatments for patients, training a new generation of clinical and translational researchers, and engaging communities in clinical research efforts. Yet, little is known about how emergency care researchers have interacted with and utilized the resources of academic institutions with CTSAs. The purpose of this survey was to describe how emergency care researchers use local CTSA resources, to ascertain what proportion of CTSA consortium members have active emergency care research programs, and to solicit participation in a national CTSA-associated emergency care translational research network. Survey of all emergency departments affiliated with a CTSA. Of the 65 CTSA consortium members, three had no emergency care research program and we obtained responses from 46 of the remaining 62 (74% response rate). The interactions with and resources used by emergency care researchers varied widely. Methodology and biostatistics support was most frequently accessed (77%), followed closely by education and training programs (60%). Several emergency care research programs (76%) had submitted for funding through CTSAs, with 71% receiving awards. Most CTSA consortium members had an active emergency care research infrastructure: 21 (46%) had 24/7 availability to recruit and screen for research, 21 (46%) had less than 24/7 research recruitment. A number of emergency care research programs participated in NIH research networks with the Neurological Emergencies Treatment Trials network most highly represented with 23 (59%) sites. Most emergency care research programs (96%) were interested in participating in a CTSA-based emergency care translational research network. Despite little initial involvement in development of the CTSA program, there has been moderate interaction between CTSAs and emergency care. There is considerable interest in participating in a CTSA consortium based emergency care translational research network. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • Leeor Eliyahu · Scott Kirkland · Sandy Campbell · Brian H. Rowe
    [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Concussions or mild traumatic brain injury (mTBI) are a major public health concern accounting for 85% of all brain injuries. Post-concussion syndrome (PCS) has been found to affect between 15-25% of patients with concussion one year after the initial injury. The goal of this review is to assess the effectiveness of early educational information or interventions provided in the Emergency Department (ED) on the onset and/or severity of PCS. Methods: A comprehensive literature search strategy involving seven electronic databases was developed. A grey literature search of Google Scholar, recent conference proceedings in Emergency Medicine, bibliographies of included studies and clinical trial registries was also performed. The citation list was reviewed independently by two reviewers; no restrictions on publication status or language of publication were applied. The Cochrane risk of bias (RoB) tool and the Newcastle-Ottawa scale (NOS) were used to assess quality. Results: From 1325 citations retrieved, four RCTs and one controlled clinical trial met inclusion criteria. Interventions identified in these studies included: educational information sheets, with or without telephone or in person follow up, and one study on bed rest. While rarely requested, one study offered referrals and additional treatment, if needed. None of the studies were deemed to be high quality. Heterogeneity among outcome reporting, follow up dates and interventions used precluded a pooled analysis. Overall, only two of the five included studies involving adult patients receiving early educational interventions reported a significant improvement in PCS symptoms. No reduction in PCS symptoms was found in the study on bed rest interventions. Conclusion: Limited evidence exists regarding the effectiveness of early educational interventions following concussion. Standardization of the interventions, outcome measures, and follow-up periods would make quantitative comparisons more valid. Moreover, higher quality research in the field of early interventions for patients in the acute care setting is urgently required. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically-important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low. Methods: This was a planned secondary analysis of a previously-conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before computed tomography (CT) as <1%, 1-5%, 6-10%, 11-50% or >50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. In order to avoid over-fitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion >1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children <2 years (pre-verbal), the other rule for children >2 years (verbal)). Results: In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2857 (33.6%) of patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2099/7688 (27.3%) of those with clinician suspicion of ciTBI of < 1% and 758/808 (93.8%) of those with clinician suspicion >1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for preverbal (100% (95% CI 86.3, 100%) versus 60.0% (95% CI 38.7, 78.9%)) and verbal children (96.8% (95% CI 88.8, 99.6%) versus 64.5% (95% CI 51.3, 76.3%)). Prediction rule specificity, however, was lower than clinician suspicion > 1% for preverbal children (53.6% (95% CI 51.5, 55.7%) versus 92.4% (95% CI 91.2, 93.5%)) and verbal children (58.2% (95% CI 56.9, 59.4%) versus 90.6% (95% CI 89.8, 91.3%)). Of the 7,688 patients in the validation group with clinician suspicion recorded as <1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI <1%. Conclusions: The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of <1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Failure to normalize lactate is associated with poor outcomes in septic shock. It has been suggested that persistently elevated lactate may result from regional ischemia due to disturbed and/or heterogenous microcirculatory blood flow. Objectives: The goal of this study was to determine if lactate clearance may serve as a surrogate marker for changes in microcirculatory blood flow in patients with septic shock. Methods: This was a prospective observational study performed within a previously published clinical trial of L-carnitine for the treatment of vasopressor-dependent septic shock. Intravital video microscopy was performed at enrollment and 12 hours later, and microcirculatory flow index (MFI) was assessed. Associations between enrollment MFI, lactate, and SOFA score were determined, in addition to associations between ∆MFI, lactate clearance, and ∆SOFA. A preplanned subgroup analysis of only patients with an elevated initial lactate was performed. Results We enrolled a total of 31 patients, 23 with survival to and sufficient quality videos both at enrollment and 12 hours. ∆MFI, lactate clearance, and ∆SOFA were 0.1 (IQR 0, 0.3), 18% (IQR -10%, 46%), and -2 (IQR -4, 0). Both ∆MFI and lactate clearance were associated with ∆SOFA (β = -5.3, p = 0.01 and β = -3.5, 0.047), but not with each other, even in the subgroup of patients with an initially elevated lactate. Conclusion: We observed no association between degree of lactate clearance and change in microcirculatory blood flow in patients with septic shock. These data suggest against the hypothesis that lactate clearance may be used as a surrogate marker of microcirculatory blood flow. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: In this issue, Probst et al present survey data assessing emergency physicians' (EPs) perceived appropriateness of shared decision making (SDM). This is particularly timely as SDM in the ED is the topic of the Academic Emergency Medicine 2016 Consensus Conference. In this study, the authors aimed to identify the clinical domains and scenarios for which EPs feel SDM is most appropriate in the ED. Findings included that respondents felt SDM was appropriate all or most of the time for invasive procedures (72%), CT imaging (57%) and discharge decisions (56%). The authors focus on the relative support for SDM across the various domains and scenarios presented and caution against deriving significant conclusions from the proportions showing support for SDM. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Sudden cardiac arrest is a major cause of death in the adult population of developed countries, with only 10-15 percent of cardiopulmonary resuscitations being successful. We aimed to compare the effects of interposed abdominal compression-cardiopulmonary resuscitation with standard cardiopulmonary resuscitation methods on end tidal CO2 and the return of spontaneous circulation following cardiac arrest in a hospital setting. Methods: After cardiac arrest was confirmed in a patient at Mashhad Ghaem Hospital, 80 cases were randomly assigned to one of the two methods of resuscitation; either interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR), or standard cardiopulmonary resuscitation (STD-CPR), respectively. The inclusion criteria for the study were: non traumatic cardiac arrest, in patients between the age of 18-85 year and the presence of endotracheal tube. Exclusion criteria were: abdominal surgery in the past two weeks, active gastrointestinal bleeding, pulmonary embolism and suspected pregnancy. Data was analyzed using SPSS Statistics for Windows version 16. Results: There was a significant difference between the two groups in end tidal CO2 (P<0.003); but there was no significant difference as far as the return of spontaneous circulation (P>0.50). Conclusion: The increase in the end tidal CO2 during interposed abdominal compression CPR is an indicator of the increase in cardiac output following the use of this method of CPR. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Prescription opioid overdoses are a leading cause of death in the United States. Emergency departments (EDs) are potentially high-risk environments for doctor shopping and diversion. The hypothesis was that opioid prescribing rates from the ED have increased over time. Methods: The authors analyzed data on ED discharges from the 2006 through 2010 NHAMCS, a probability sample of all U.S. EDs. The outcome was documentation of an opioid prescription on discharge. The primary independent predictor was time. Covariates included severity of pain, a pain-related discharge diagnosis, age, sex, race, payer, hospital ownership, and geographic location of hospital. Up to three discharge diagnoses were available in NHAMCS to identify "pain-related" (e.g., back pain, fracture, dental/jaw pain, nephrolithiasis) ED visits. Multivariate logistic regression was performed to assess the independent associations between opioid prescribing and predictors. All analyses incorporated NHAMCS survey weights, and all results are presented as national estimates. Results: Opioids were prescribed for 18.7% (95% confidence interval = 17.7% to 19.7%) of all ED discharges, representing 18.8 million prescriptions per year. There were no significant temporal trends in opioid prescribing overall (adjusted p = 0.93). Pain-related discharge diagnoses that received the top three highest proportion of opioids prescriptions included nephrolithiasis (62.1%), neck pain (51.6%), and dental/jaw pain (49.7%). A pain-related discharge diagnosis, non-Hispanic white race, older age, male sex, uninsured status, and Western region were positively associated with opioid prescribing (p < 0.05). Conclusions: No temporal trend toward increased prescribing from 2006 to 2012 was found. These results suggest that problems with opioid overprescribing are multifactorial and not solely rooted in the ED.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: To maintain certification by the American Board of Emergency Medicine (ABEM), physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. On the 2014 ConCert postexamination survey, ABEM sought to understand the manner in which ABEM diplomates prepared for the test and to identify associations between test preparation approaches and performance on the ConCert examination. Methods: This was a cross-sectional survey study. The survey was administered at the end of the 2014 ConCert examination. Analyses included chi-square and linear regression to determine the association of preparation methods with performance. Results: Of the 2,431 on-time test-takers, 2,338 (96.2%) were included. The most commonly used study approach was the review of written materials designed for test preparation (1,585; 67.8%), followed by an online training course (1,006; 43.0%). There were 758 (32.4%) physicians who took a single onsite board review course, while 41 (1.8%) took two or more onsite courses. Most physicians (1,611; 68.9%) spent over 35 hours preparing for the ConCert examination. The study method that was most associated with favorable test scores was the review of written materials designed for test preparation (p < 0.001). Attending an onsite preparation course was associated with poorer performance (p < 0.001). There was a significant association between no additional preparation and failing the examination (chi-square with Yates correction; p = 0.001). Conclusions: A substantial majority (97.8%) of physicians taking the 2014 ABEM ConCert examination prepared for it. The majority of physicians used written materials specifically designed for test preparation. Reviewing written materials designed for test preparation was associated with the highest performance.
    No preview · Article · Jan 2016 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: The pyruvate dehydrogenase complex (PDH) is an essential enzyme in aerobic metabolism;. Ketones are known to inhibit PDH activity, but the extent of this inhibition is unknown in patients with diabetic ketoacidosis (DKA). Research design and methods: We enrolled adult patients presenting to the emergency department in hyperglycemic crisis. Patients were classified as DKA or hyperglycemia without ketoacidosis based on laboratory criteria. Healthy controls were also enrolled. PDH activity and quantity were measured in isolated peripheral blood mononuclear cells. We compared PDH values between groups and measured the relationship of PDH values to measures of acid-base status. Results: 27 patients (17 with DKA) and 31 controls were enrolled. Patients with DKA had lower PDH activity and quantity as compared to the two other groups. PDH activity was significantly correlated with serum bicarbonate and pH, and inversely correlated with the anion gap. Conclusion: DKA is associated with greater suppression of PDH activity than hyperglycemia without ketoacidosis, and this is correlated with measures of acid-base status. Future studies may determine whether PDH depression plays a role in the pathophysiology of DKA and whether modification of PDH could decrease time to DKA resolution. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Academic Emergency Medicine