Journal of Emergencies, Trauma, and Shock
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   2018| April-June  | Volume 11 | Issue 2  
    Online since May 29, 2018

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Bedside lung ultrasound in emergency protocol as a diagnostic tool in patients of acute respiratory distress presenting to emergency department
Chirag J Patel, Hardik B Bhatt, Samira N Parikh, Binit N Jhaveri, Jyothi H Puranik
April-June 2018, 11(2):125-129
DOI:10.4103/JETS.JETS_21_17  PMID:29937643
Objective: The objective of this study is to determine the accuracy of the bedside lung ultrasound in emergency (BLUE) protocol in giving a correct diagnosis in patients presenting with acute respiratory distress in emergency department. Materials and Methods: Patients with acute respiratory distress were evaluated. Ultrasound findings such as artifacts (A line, B line), lung sliding, alveolar consolidation or pleural effusion, and venous analysis were recorded. Ultrasonography findings were correlated with final diagnosis made by the treating unit. Sensitivity and specificity were calculated. Results: A total 50 patients were evaluated. The A profile (predominant A line with lung sliding) indicated chronic obstructive pulmonary disease/asthma (n = 14) with 85.17% sensitivity and 88.88% specificity. B profile (predominant B + lines with lung sliding) indicated pulmonary edema (n = 13) with 92.30% sensitivity and 100% specificity. The A/B profile (A line on one side and B + line on other side) and the C profile (anterior consolidation) and the A profile plus posterolateral alveolar and/or pleural syndrome indicated pneumonia (n = 17) with 94.11 sensitivity and 93.93% specificity. The A profile plus venous thrombosis indicated pulmonary embolism (n = 1) with 100% sensitivity and specificity. A' profile (predominant A line without lung sliding) with lung point indicated pneumothorax (n = 5) with 80% sensitivity and 100% specificity. Conclusion: BLUE protocol was successful in average 90.316% cases. BLUE performed in emergency department is equivalent to computed tomography scan. BLUE protocol aids in making diagnosis and saves time and cost; avoids the side effects related to radiation.
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Grace under pressure: Leadership in emergency medicine
Fatimah Lateef
April-June 2018, 11(2):73-79
DOI:10.4103/JETS.JETS_18_18  PMID:29937634
Physicians in general, including emergency physicians (EPs), are trained in the diagnostic, therapeutic, and administrative aspects of patient care but not so much in the theoretical and practical aspects of assuming and delivery of leadership. EPs are always taught to focus on their performance, to excel and achieve, to be accountable for their own clinical decisions, and to appreciate feedback and peer-to-peer review. Currently, if there are some semblances of formal or semi-formal leadership instruction, the organized theoretical curriculum often does not formally include very structured and planned departmental leadership and management elements. Leadership is a process for a person (≥the leader≥) to lead, influence, and engage a group or organization to accomplish their objectives and mission. To do this, the leader must understand a variety of issues of working, interacting, and integrating with people, the environment and both, the intrinsic and extrinsic factors, and elements that have an impact on the industry or area he/she is leading in. Leadership in emergency medicine (EM) is even more challenging, with its unique focus, issues, and trajectory, moving into the new century, with new considerations. No single strategy is sufficient to ace EM leadership and no single specific leadership model is complete. This paper shares some current views on medical/EM leadership. The author shares her views and some suggested proposals for more formal and structured leadership, implementation, and succession to help nurture and groom Eps who will become leaders in EM in the near future.
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Guiding management in severe trauma: Reviewing factors predicting outcome in vastly injured patients
Emmanuel Lilitsis, Sofia Xenaki, Elias Athanasakis, Eleftherios Papadakis, Pavlina Syrogianni, George Chalkiadakis, Emmanuel Chrysos
April-June 2018, 11(2):80-87
DOI:10.4103/JETS.JETS_74_17  PMID:29937635
Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome – specifically mortality risk – in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome – more specifically mortality risk – in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured.
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Integration of point-of-care ultrasound during rapid sequence intubation in trauma resuscitation
Prakash Ranjan Mishra, Sanjeev Bhoi, Tej Prakash Sinha
April-June 2018, 11(2):92-97
DOI:10.4103/JETS.JETS_56_17  PMID:29937637
Introduction: Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation. Methods: It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were divided into ultrasonography (USG) and clinical examination (CE) arm. The objectives were to study the utility of POCUS in endotracheal tube placement and confirmations and identification of potentially fatal conditions as tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathology, pneumothorax, and others during RSI. Patient >1 year of age were included. Time taken for procedure, number of incorrect intubations, and pathologies detected were noted. The data were collected in Microsoft Excel spread sheets and analyzed using Stata (version 11.2, Stata Corp, Texas, U. S. A) software. Results: One hundred and six patients were recruited. The mean time for primary survey USG versus CE arm was (20 ± 10.01 vs. 18 ± 11.03) seconds. USG detected four pneumothorax, one tracheal injury, and one paratracheal hematoma. The mean procedure time USG versus CE arm was (37.3 ± 21.92 vs. 58 ± 32.04) seconds. Eight esophageal intubations were identified in USG arm by POCUS and two in CE arm by EtCO2 values. Conclusion: Integration of POCUS was useful in all three phases of RSI. It identified paratracheal hematoma, tracheal injury, and pneumothorax. It also identified esophageal intubation and confirmed main stem tracheal intubation in less time compared to five-point auscultation and capnography.
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Snakebites in lebanon: a descriptive study of snakebite victims treated at a tertiary care center in Beirut, Lebanon
Tharwat El Zahran, Ziad Kazzi, Ahel Al-Hajj Chehadeh, Riyad Sadek, Mazen J El Sayed
April-June 2018, 11(2):119-124
DOI:10.4103/JETS.JETS_141_16  PMID:29937642
Background: Snakebites lead to at least 421,000 envenomations and result in more than 20,000 deaths per year worldwide. Few reports exist in the Mediterranean region. This study describes demographic and clinical characteristics, treatment modalities, and outcomes of snakebites in Lebanon. Materials and Methods: This was a retrospective chart review of patients who presented with snakebite complaint to the emergency department between January 2000 and September 2014. Results: A total of 24 patients were included in this study. The mean age was 34.6 (±16.4) years and 58.3% were males. Local manifestations were documented in 15 (62.5%) patients, systemic effects in 10 (41.7%), hematologic abnormalities in 10 (41.7%), and neurologic effects in 4 (16.7%) patients. Nine patients (37.5%) received antivenom. The median amount of antivenom administered was 40 ml or 4 vials (range: 1–8 vials). About 50% of patients were admitted to the hospital with 75% to an Intensive Care Unit and 25% to a regular bed. All were discharged home with a median hospital length of stay of 4 (interquartile range 11) days. Among those admitted, seven patients (58.3%) had at least one documented complication (compartment syndrome, fasciotomy, intubation, deep vein thrombosis, coagulopathy, acute respiratory distress syndrome, sepsis, congestive heart failure, cellulitis, upper gastrointestinal bleeding, and vaginal bleeding). Conclusion: Victims of snakebites in Lebanon developed local, systemic, hematologic, or neurologic manifestations. Complications from snakebites were frequent despite antivenom administration. Larger studies are needed to assess the efficacy of available antivenom and to possibly create a local antivenom for the treatment of snakebites in Lebanon.
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Inferior vena cava obstruction and shock
Megri Mohammed, Shaheed Elhamdani, Waiel Abusnina, Aldliw Majdi, Shweihat Yousef
April-June 2018, 11(2):146-148
DOI:10.4103/JETS.JETS_22_17  PMID:29937648
Shock is one of the most challenging life-threatening conditions with high mortality and morbidity; the outcomes are highly dependent on the early detection and management of the condition. Septic shock is the most common type of shock in the Intensive Care Unit. While not as common as other subsets of shock, obstructive shock is a significant subtype due to well defined mechanical and pathological causes, including tension pneumothorax, massive pulmonary embolism, and cardiac tamponade. We are presenting a patient with obstructive shock due to inferior vena cava obstruction secondary to extensive deep venous thrombosis. Chance of survival from obstructive shock in our patient was small; however, there was complete and immediate recovery after treatment of the obstruction on recognizing the affected vessels. This case alerts the practicing intensivist and the emergency medicine physician to consider occlusion of the great vessels other than the pulmonary artery or aorta as causes of obstructive shock.
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Validation of the cincinnati prehospital stroke scale
Aditya Maddali, Farook Abdul Razack, Srihari Cattamanchi, Trichur V Ramakrishnan
April-June 2018, 11(2):111-114
DOI:10.4103/JETS.JETS_8_17  PMID:29937640
Background: Early recognition of Stroke is one of the key concepts in the ≤Chain of Survival≥ as described by the American Heart Association/American Stroke Association Stroke guidelines. The most commonly used tools for prehospital assessment of stroke are ≤The Cincinnati Prehospital Stroke Scale,≥ (CPSS) the ≤Face, Arm, Speech Test,≥ and ≤The Los Angeles Prehospital Stroke Screen.≥ The former two are used to identify stroke using physical findings while the latter is used to rule out other causes of altered consciousness. Aim: The aim of this study is to validate the CPSS in the prehospital setting by correlating with computed tomography scan findings. (1) To determine if these scores can be implemented in the Indian prehospital setting. (2) To determine if it is feasible for new emergency departments (EDs) to use these protocols for early detection of stroke. Methodology: A prospective, observational study from December, 2015 to March, 2016. Patients with suspected stroke were enrolled. Data were collected prehospital in patients that arrived to the ED in an ambulance. Sensitivity, specificity, positive predictive value, and negative predictive value of the score were calculated using standard formulae. Results: CPSS showed good sensitivity of 81% (confidence interval [CI] – 68.5%–97%) when combined and a positive predictive value (PPV) of 100% (CI: 91.9%–100%). Individually, they showed a sensitivity of 75.8%, 79%, and 74.1%, respectively, with a PPV of 100% and specificity of 95%–100%. Conclusion: As a prehospital screening tool, CPSS can be extremely useful as any diagnosis is only provisional until confirmed by an appropriate investigation in a hospital.
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Comparison of ultrasound and plain radiography for the detection of long-bone fractures
Amit Bahl, Michael Bagan, Steven Joseph, Abigail Brackney
April-June 2018, 11(2):115-118
DOI:10.4103/JETS.JETS_82_17  PMID:29937641
Objective: To compare emergency medicine (EM) resident physicians' ability to identify long-bone fractures using ultrasound (US) versus plain radiography (X-ray). Methods: This was an IRB-approved, randomized prospective study. Study participants included 40 EM residents at a single site. Fractures were mechanically induced in five chicken legs, and five legs were left unfractured. Chicken legs were imaged by both modalities. Participants were given 2 min to view each of the images. Participants were randomized to either US or X-ray interpretation first and randomized to viewing order within each arm. Participants documented the presence or absence of fracture and location and type of fracture when pertinent. Mean proportions and standard deviations (SDs) were analyzed using paired t-test and linear models. Results: Forty residents (15 postgraduate years (PGY)-1, 12 PGY-2, 13 PGY-3) participated in the study. Thirty-one participants were male, and 19 were randomized to US first. Residents completed a mean of 185 (SD 95.8) US scans before the study in a variety of applications. Accurate fracture identification had a higher mean proportion in the US arm than the X-ray arm, 0.89 (SD 0.11) versus 0.75 (SD 0.11), respectively (P < 0.001). There was no statistically significant difference in US arm and X-ray arm for endpoints of fracture location and type. Conclusion: EM residents were better able to identify fractures using US compared to X-ray, especially as level of US and ED experience increased. These results encourage the use of US for the assessment of isolated extremity injury, particularly when the injury is diaphyseal.
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Validation of predicting hyperglycemic crisis death score: A risk stratification tool for appropriate disposition of hyperglycemic crisis patients from the emergency department
Akilan Elangovan, Srihari Cattamanchi, Abdul Razack Farook, Ramakrishnan Venkatakrishnan Trichur
April-June 2018, 11(2):104-110
DOI:10.4103/JETS.JETS_2_17  PMID:29937639
Context: Predicting hyperglycemic crisis death (PHD) score is a simple, rapid tool with six independent mortality predictors to calculate 30-day mortality and appropriately dispose patients to Intensive Care Unit (ICU) or ward. Aims: This study aimed at validating the efficiency of PHD score as a decision rule for prognosticating 30-day mortality and classifying hyperglycemic crisis patients for appropriate disposition from the emergency department (ED). Materials and Methods: This is a prospective, observational study done in the ED of a teaching hospital over 14 months. All patients aged >18 years and who met the criteria of hyperglycemic crisis were enrolled. Thirty-day mortality of six independent predictors was the primary end point. Using PHD, risk scores were calculated and patients were disposed as per physician's clinical judgment. Finally, the treating physician's decision and PHD score disposition were compared and the efficiency of PHD in predicting 30-day mortality was analyzed. Multiple logistic regression models were used for analysis. Receiver operating characteristic curve was drawn, and area under the curve along with sensitivity, specificity, positive predictive value, and negative predictive value was analyzed. P < 0.05 was considered statistically significant. Results: A total of 133 patients were included. On applying PHD score, 69, 39, and 25 patients were in the low-, intermediate-, and high-risk groups, respectively, with a mortality rate of 5.8%, 20.5%, and 56%, respectively. On comparing physician disposition with PHD score, an increasing mortality was noticed in ICU, and PHD showed equal weight in risk stratification and appropriate disposition of patients. Conclusion: In adult patients with hyperglycemic crisis, PHD score is validated as a straightforward, prompt tool for predicting 30-day mortality and aids in disposition. The mortality rate in the PHD score Model II was similar to the physician's clinical decision.
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Amitraz poisoning: The (Un) common poisoning
William Wilson, Shakuntala Murty
April-June 2018, 11(2):140-142
DOI:10.4103/JETS.JETS_33_17  PMID:29937646
Pesticide poisoning is always a clinical conundrum for the emergency physician (EP), the complexity of which increases when the pesticide has no antidote! Over the past decade, there has been a sharp increase in cases of Amitraz poisoning, a pesticide routinely used in veterinary medicine, available without a prescription. The usual presentation includes bradycardia, hypotension, poor sensorium, and miosis. In the absence of accurate history, these clinical features can be confused with the cholinergic toxidrome of organophosphorus poisoning. There is a dearth of literature regarding the presentation and protocols for the management of Amitraz poisoning with data mostly based on animal studies and pediatric case reports. Currently, the available medical literature in the form of case reports and case series form an invaluable source of information to the EP to formulate a working diagnosis and methodical approach to this pesticide. Here, we present two case reports highlighting the characteristic clinical features and bringing to light how an organized approach to the toxin can give satisfactory results.
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Utility of abdominal computed tomography in geriatric patients on warfarin with a fall from standing
Amit Bahl, Steven Schafer
April-June 2018, 11(2):88-91
DOI:10.4103/JETS.JETS_52_17  PMID:29937636
Context: Geriatric head trauma resulting from falls has been extensively studied both in the presence and absence of blood thinners. In this population, however, the prevalence and extent of abdominal injury resulting from falls are much less defined. Aim: We aim to evaluate the utility of abdominal computed tomography (CT) imaging in geriatric patients on Warfarin with a recent history of fall. Setting and Design: A retrospective analysis was completed of consecutive geriatric patients who presented to a Level 1 Trauma Center emergency department after fall from standing while taking Warfarin. Methods: Inclusion criteria included age 65 years or older and fall while taking Warfarin. Incomplete medical records were excluded from the study. Data collection included the type of anticoagulant medications, demographics, physical examination, laboratories, CT/X-ray findings if ordered, and final diagnosis on admission. Categorical variables were examined using Pearson's Chi-square where appropriate (expected frequency >5), or Fisher's Exact test. Continuous variables were examined using nonparametric Wilcoxon rank tests. Results: Eight hundred and sixty-three charts were reviewed. One hundred and thirty-one subjects met inclusion criteria. Mean age was 83 years. Nearly 39.6% of patients were male. A total of 48 patients had abdominal CT imaging. Seven of the 131 patients (5.3%) had an abdominal injury. Abdominal tenderness was predictive of injury, with 4 of 7 cases with abdominal injury demonstrating abdominal tenderness versus only 10 of 124 cases without abdominal injury demonstrating tenderness (P = 0.003). Abdominal CTs were ordered in 11 of 19 cases of patients that exhibited head trauma yet none of these patients were shown to have sustained abdominal trauma (P = 0.08). There was no association between international normalized ratio level and presence of abdominal injury (P = 0.99). Conclusions: A small percentage of elderly fall patients on Warfarin have a significant abdominal injury. Anticoagulated geriatric patients are sometimes subjected to abdominal scans liberally without supporting physical examination findings such as abdominal tenderness or presence of a distracting injury. Specifically, the utility of abdominal CT is questionable in isolated head injury patients. Further, taking Warfarin or other anticoagulant medications do not seem to increase the risk of intraabdominal injury.
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A pilot study of viscoelastic monitoring in pediatric trauma: Outcomes and lessons learned
Bola Aladegbami, Pamela M Choi, Martin S Keller, Adam M Vogel
April-June 2018, 11(2):98-103
DOI:10.4103/JETS.JETS_150_16  PMID:29937638
Background: Examine the characteristics and outcomes of pediatric trauma patients at risk for coagulopathy following implementation of viscoelastic monitoring. Materials and Methods: Injured children, aged <18 years, from September 7, 2014, to December 21, 2015, at risk for trauma-induced coagulopathy were identified from a single, level-1 American College of Surgeons verified pediatric trauma center. Patients were grouped by coagulation assessment: no assessment (NA), conventional coagulation testing alone (CCT), and conventional coagulation testing with rapid thromboelastography (rTEG). Coagulation assessment was provider preference with all monitoring options continuously available. Groups were compared and outcomes were evaluated including blood product utilization, Intensive Care Unit (ICU) utilization, duration of mechanical ventilation, and mortality. Results: A total of 155 patients were identified (NA = 78, CCT = 54, and rTEG = 23). There was no difference in age, gender, race, or mechanism. In practice, rTEG patients were more severely injured, more anemic, and received more blood products and crystalloid (P < 0.001). rTEG patients also had increased mortality with fewer ventilator and ICU-free days. Multivariate logistic regression and covariance analysis indicated that while rTEG use was not associated with mortality, it was associated with increased use of blood products, duration of mechanical ventilation, and ICU length of stay. Conclusions: Viscoelastic monitoring was infrequently performed, but utilized in more severely injured patients. Well-designed prospective studies in patients at high risk of coagulopathy are needed to evaluate goal-directed hemostatic resuscitation strategies in children.
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What's new in emergencies, trauma, and shock? Using abdominal computed tomography in geriatric patients on warfarin
Dorian A Bogdanovski, Daniel Hakakian, Louis T DiFazio, Luca Antonioli, Zoltan H Nemeth
April-June 2018, 11(2):71-72
DOI:10.4103/JETS.JETS_85_17  PMID:29937633
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Measurement of a novel biomarker, secretory phospholipase A2 group IIA as a marker of sepsis: A pilot study
Elena Berg, Janel Paukovits, Jennifer Axelband, Jonathan Trager, Dina Ryan, Kathleen Cichonski, Mark Kopnitsky, Daniel Zweitzig, Rebecca Jeanmonod
April-June 2018, 11(2):135-139
DOI:10.4103/JETS.JETS_29_17  PMID:29937645
Introduction: Early identification of sepsis is critical as early treatment improves outcomes. We sought to identify threshold values of secretory phospholipase A2 (sPLA2)-IIA that predict sepsis and bacterial infection compared to nonseptic controls in an emergency department (ED) population. Materials and Methods: This is a prospective cohort of consenting adult patients who met two or more systemic inflammatory response syndrome (SIRS) criteria with clinical diagnosis of infectious source likely (septic patients). Controls were nonseptic consenting adults undergoing blood draw for other ED indications. Both groups had blood drawn, blind-coded, and sent to an outside laboratory for quantitative analysis of sPLA2-IIA levels. The study investigators reviewed patients' inpatient medical record for laboratory, imaging, and microbiology results, as well as clinical course. Results: sPLA2-IIA levels were significantly lower in control patients as compared to septic patients (median = 0 ng/ml [interquartile range (IQR): 0–6.5] versus median = 123 ng/ml [IQR 44–507.75]; P < 0.0001). SPLA2-IIA levels were higher in patients with confirmed source (n = 28 patients, median = 186 ng/ml, 95% confidence interval = 115.1–516.8) as compared to those with no source identified or a viral source (n = 17, median = 68 ng/ml, 95% confidence interval = 38.1–122.7; P = 0.04). Using a cutoff value of 25 ng/ml, sPLA2-IIA had a sensitivity of 86.7% (confidence interval 72.5–94.5) and a specificity of 91.1% (confidence interval 77.9–97.1) in detecting sepsis. Conclusions: sPLA2-IIA shows potential as a biomarker distinguishing sepsis from other disease entities. Further study is warranted to identify predictive value of trends in sPLA-IIA during disease course in septic patients.
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Acute appendicitis as an unexpected cause of inverted takotsubo cardiomyopathy
Mihaela Mihalcea-Danciu, Michel Zupan, Pierrick Le Borgne, Pascal Bilbault
April-June 2018, 11(2):143-145
DOI:10.4103/JETS.JETS_13_17  PMID:29937647
Takotsubo cardiomyopathy (TTC), also known as transient left ventricular ballooning syndrome, is a stress-induced-cardiomyopathy. It is precipitated by emotional or physical stress and is characterized by normal coronary arteries and transient regional wall motion abnormalities. Variants of TTC include apical ballooning syndrome and, less commonly, mid, basal, and local variants. New onset heart failure or acute coronary syndromes are a common presentation of TTC. Arrhythmias such as VT, VF, and torsade de pointes have also been reported. We present here a 42-year-old man with an inverted Takotsubo variant with pulmonary edema and transient accelerated idioventricular rhythm. He was initially admitted in the Emergency Department for acute and non-complicated appendicitis. Coronary angiogram showed normal coronary arteries and left ventriculography revealed a reverse variant of TTC. The patient had completely recovered. Myocarditis was ruled out by cardiac magnetic resonance imaging.
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True costs of medical clearance: Accuracy and disagreement between psychiatry and emergency medicine providers
Laura N Medford-Davis, Nidal Moukaddam, Anu Matorin, Asim Shah, Veronica Tucci
April-June 2018, 11(2):130-134
DOI:10.4103/JETS.JETS_125_16  PMID:29937644
Introduction: Medical clearance is required to label patients with mental illness as free of acute medical concerns. However, tests may extend emergency department lengths of stay and increase costs to patients and hospitals. The objective of this study was to determine how knowledgeable emergency and psychiatric providers are about the costs of tests used for medical clearance. Materials and Methods: We surveyed the department of psychiatry (Psych) and department of emergency medicine (EM) faculty and residents to obtain their estimates of the costs of 18 laboratory/imaging studies commonly used for medical clearance. Survey responses were analyzed using the Wilcoxon signed-rank test to compare the median cost estimates between residents and faculty in EM and Psych. Results: A total of 99 physicians (response rate, 47.8%) completed the survey, including 47 faculty (EM = 28; Psych = 20) and 52 residents (EM = 29; Psych = 23). Across all the groups, cost estimates for tests were inaccurate, off by several hundred dollars for three tests, and by $13–$80 for 15. Significant differences between EM and Psych providers for estimated median costs of specific tests included between residents for urine drug screens (EM: $800; Psych: $50; P < 0.0001) and ECG (EM: $25; Psych: $75; P = 0.004); between faculty for urinalysis (EM: $40; Psych: $18; P = 0.020) and urine drug screen (EM: $100; Psych: $10; P < 0.0001); and between all physicians for urine drug screen (EM: $500; Psych: $50; P < 0.0001). Conclusion: Further education on the financial costs of medical clearance is needed to inform workup decisions and consensus between emergency and psychiatric providers.
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Mild traumatic brain injury associated with internal carotid artery dissection and pseudoaneurysm
Wellingson Silva Paiva, Barbara Albuquerque Morais, Almir Ferreira de Andrade, Manoel Jacobsen Teixeira
April-June 2018, 11(2):151-151
DOI:10.4103/JETS.JETS_31_17  PMID:29937650
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Concomitance acute cerebral infarction and remote intra-cerebral hemorrhaging on arrival
Takashi Iso, Youichi Yanagawa, Ikuto Takeuchi, Satoru Suwa
April-June 2018, 11(2):149-150
DOI:10.4103/JETS.JETS_118_17  PMID:29937649
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