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No Easy Way Out: A Case of Physician-Assisted Dying in the Emergency Department.
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No Easy Way Out: A Case of Physician-Assisted Dying in the Emergency Department.

Ann Emerg Med. 2017 Oct 12;:

Authors: Wang DH

Abstract
Currently, 1 out of 6 Americans lives within a jurisdiction in which physician-assisted dying is legally authorized. In most cases, patients ingest lethal physician-assisted dying medications at home without involvement of emergency medical services (EMS) or the emergency department (ED). However, occasionally the dying process is interrupted as a result of incomplete ingestion or vomiting of medications, confusion about timing of dying trajectory, familial emotional distress, and other variables. A case is presented here of a patient who arrived by ambulance to an urban ED after ingesting physician-assisted dying medication. Stepwise analysis of communication and actions between providers (paramedics, emergency physician, and admitting physician), risk management, and family are described chronologically. This case highlights the significant distress experienced by each party, as well as key challenges and learning points. Guidance is provided to emergency providers about expectations and communication. In states with limited physician-assisted dying experience, many EMS agencies, EDs, and hospitals require comprehensive protocols to handle the complex ethical and psychosocial issues surrounding physician-assisted dying in the ED.

PMID: 29033297 [PubMed - as supplied by publisher]




A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine.
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A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine.

Ann Emerg Med. 2017 Oct 13;:

Authors: Zitek T, Gates M, Pitotti C, Bartlett A, Patel J, Rahbar A, Forred W, Sontgerath JS, Clark JM

Abstract
STUDY OBJECTIVE: Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED.
METHODS: This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache.
RESULTS: There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes.
CONCLUSION: Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.

PMID: 29033296 [PubMed - as supplied by publisher]




Can Multidetector Computed Tomography Rule Out Left Atrial Thrombus in Patients With Atrial Fibrillation?
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Can Multidetector Computed Tomography Rule Out Left Atrial Thrombus in Patients With Atrial Fibrillation?

Ann Emerg Med. 2017 Oct 13;:

Authors: Solie CJ, Mohr NM, Runde DP

PMID: 29033295 [PubMed - as supplied by publisher]




Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.
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Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.

Ann Emerg Med. 2017 Oct 13;:

Authors: Ridderikhof ML, Lirk P, Goddijn H, Vandewalle E, Schinkel E, Van Dieren S, Kemper EM, Hollmann MW, Goslings JC

Abstract
STUDY OBJECTIVE: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.
METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia.
RESULTS: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin.
CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

PMID: 29033294 [PubMed - as supplied by publisher]




Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications.
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Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications.

Ann Emerg Med. 2017 Oct 09;:

Authors: Levine M, Beuhler MC, Pizon A, Cantrel FL, Spyres MB, LoVecchio F, Skolnik AB, Brooks DE

Abstract
STUDY OBJECTIVE: In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications.
METHODS: This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10-year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major.
RESULTS: A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0).
CONCLUSION: Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.

PMID: 29032872 [PubMed - as supplied by publisher]




Can a Negative High-Sensitivity Troponin Result Rapidly Rule Out Acute Myocardial Infarction?
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Can a Negative High-Sensitivity Troponin Result Rapidly Rule Out Acute Myocardial Infarction?

Ann Emerg Med. 2017 Oct 09;:

Authors: Finnerty NM, Weinstock MB

PMID: 29032871 [PubMed - as supplied by publisher]




Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016.
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Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016.

Ann Emerg Med. 2017 Oct 04;:

Authors: Chou SC, Deng Y, Smart J, Parwani V, Bernstein SL, Venkatesh AK

Abstract
STUDY OBJECTIVE: We examine the availability of follow-up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition.
METHODS: We used "secret shopper" methodology, employing 2 black men to telephone all 53 primary care practices in greater New Haven, posing as new patients discharged from the ED and requesting follow-up appointments. Each practice received 6 scripted calls from each caller during an 8-month period, reflecting all possible scenarios based on 3 insurance types (Medicaid, state exchange, and commercial) and 2 conditions (hypertension and back pain). Primary outcome was the proportion of calls that obtained an appointment in 7 calendar days (7-day appointment rate). Secondary outcomes included overall appointment rate and appointment wait time.
RESULTS: Among the total of 604 calls completed, the 7-day appointment rate was 30.7% (95% confidence interval [CI] 22.6% to 38.8%). Compared with commercial insurance, Medicaid calls had lower 7-day rate (25.5% versus 35.7%; difference 10.2%; 95% CI 2.2% to 18.1%) and overall appointment rate (53.5% versus 77.8%; difference 24.4%; 95% CI 13.4% to 35.4%). There was no significant difference between state exchange and commercial insurance calls in 7-day rate (30.9% versus 35.7%; difference 4.8%; 95% CI -3.1% to 12.6%) or overall appointment rate (73.4% versus 77.8%; difference 4.4%; 95% CI -2.7% to 11.6%). Back pain, compared with hypertension, had lower 7-day appointment rate (27.6% versus 33.7%; difference 6.1%; 95% CI 1.0% to 11.2%), but no significant difference in overall appointment rates (67.0% versus 69.4%; difference 2.4%; 95% CI -2.7% to 7.5%).
CONCLUSION: For patients without established primary care, obtaining timely follow-up after acute care in the ED is difficult, particularly for Medicaid beneficiaries.

PMID: 29032870 [PubMed - as supplied by publisher]




SEP-1: A Sepsis Measure in Need of Resuscitation?
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SEP-1: A Sepsis Measure in Need of Resuscitation?

Ann Emerg Med. 2017 Oct 09;:

Authors: Allison MG, Schenkel SM

PMID: 29032869 [PubMed - as supplied by publisher]




What Measures Improve Reduction of Intussusception in Pediatric Patients?
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What Measures Improve Reduction of Intussusception in Pediatric Patients?

Ann Emerg Med. 2017 Oct 09;:

Authors: Long B, April MD

PMID: 29032868 [PubMed - as supplied by publisher]