Emergency Room

Pharyngeal perforations are uncommon in children and are usually secondary to instrumentation or external penetrating injuries. A delay in management can lead to life-threatening complications such as ret-ropharyngeal abscess, mediastinitis, and airway com-promise. We report ...

Rapid advances in biosensors have recently been reported. This has been possible due to rapid growth in the development of new biomaterials such as conducting polymers, copolymers and sol gels etc and the reported improvements in sensing techniques. Biosensors are miniaturized devices employing biochemical molecular recognition as the basis for a selective analysis. The response generated as a result of biochemical reaction is detected by a transducer to give a signal (optical/electrical/thermal) that can be used with or without amplification for the estimation of the concentration of an analyte in a given test sample. Among the various biosensors, electrochemical sensors, especially amperometric biosensors presently hold a leading position.Due to specificity, portability, simplicity, high sensitivity, potential ability for real-time and on-site analysis coupled with the speed and low cost, biosensors have been projected to have applications in food analysis, environment control, clinical detection, drug and agriculture industries etc. Besides this, biosensors offer exciting opportunities for numerous decentralized clinical applications, ranging from emergency room screening, home self testing and alternative site testing, continuous and real-time in vivo monitoring. New generation of biosensors combining new bioreceptors with the ever-growing number of transducers is emerging. The present paper highlights some of the recent advances in the area of biosensors contributed by our laboratory.

We measure the effect of urban hospital closure on the operating efficiency of the remaining hospitals in the local market. Closure of a hospital other than the least efficient can be detrimental to social welfare because treatment costs will be higher at surviving hospitals. The results show that hospital closure has led to an evolutionary increase in efficiency in urban

An earthquake planning scenario document was recently released by the USGS and California Geological Survey that hypothesizes the occurrence and effects of a MW7.8 earthquake on the southern San Andreas Fault. It was created by more than 300 scientists and engineers. Fault offsets reach 13m, and up to 8m at lifeline crossings. Physics-based modeling was used to generate maps of

This paper presents a brief introduction of rapid urbanization and its consequences for air pollution in Asia. The second section elaborates local capacity for urban air quality management (UAQM). The third section discusses the capacity building process with an emphasis on the role of international environmental cooperation. The fourth section highlights Kitakyushu Initiative as an example of international cooperation for local capacity building. The fifth section discusses two successful case studies for UAQM. The sixth section briefly captures the challenges for UAQM in Asian cities. The seventh section puts a few policy recommendations. The eighth section concludes this paper. 1. Urbanization and urban environmental challenges Urban environmental challenges have become the top priority agenda for environmental governance. The environmental challenges, as a result of rapid urbanization, coupled with lower capacity to manage these problems are drastically damaging the local as wel...

Background: Stroke is a time-dependent emergency. Most patients with acute ischemic stroke are excluded from reperfusion therapies due to late consultation. Aims: To estimate the arrival times of patients with stroke to the Emergency Room (ER) of a public hospital. To identify factors associated with early consultation. Material and Methods: A convenience sample, 583 patients aged 71 ± 13 years (55% males) consulting for stroke at an emergency room was analyzed in terms of delay between onset of symptoms and arrival to the ER, demographics
and etiology of stroke. Results: The admission diagnoses were ischemic stroke in 76%, intracerebral hemorrhage in 12%, transient ischemic attack in 9% and subarachnoid hemorrhage in 3%. The median time of arrival was 8 hours and 11 minutes after the onset of symptoms. Nineteen percent of consultations for ischemic stroke occurred within 3 hours of symptom onset, and 38% within 6 hours. In the logistic regression analysis, having an address near the hospital and the severity of stroke were associated with early consultation with a combined odds ratio of 5.97 (95% confidence intervals 3.23-11.04). Conclusions: There
were significant differences in the arrival times of patients with stroke. Only a low proportion of patients with ischemic stroke consulted within the window for reperfusion therapies. Severe strokes and living near the hospital were associated with early consultation.

The current study aims to compare positive and negative measures of psychosocial functioning among children with sickle cell disease (SCD) and their healthy siblings. Participants were 41 African-American children with SCD, 97 healthy siblings, and their primary caregivers. Primary caregivers completed self-report questionnaires assessing child behavioral problems, while children with SCD and siblings completed self-report questionnaires assessing coping, self-efficacy, and perceived social support. No significant differences were noted between children with SCD and their siblings on all measures. Both groups reported self-efficacy and perceived social support within the normative range, and endorsed significantly greater use of Positive/Approach coping. In general, both groups of children do not have clinically significant behavioral problems. However, secondary exploratory analyses identified that a greater percentage of children from both groups scored above the established clinical cutoff on the behavioral summary scores. Number of visits to the emergency room was related to behavioral problems in children with SCD. While previous reports have been mixed in their findings that children with SCD are at greater risk for psychosocial and other behavioral problems, the current report finds that children with SCD and their healthy siblings endorse positive psychosocial functioning and as a group do not have clinically significant behavioral problems. Nonetheless, ongoing psychosocial evaluation for children receiving treatment for SCD is vital.

Background: Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels.Study Design: Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period.Results: Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location.Conclusions: Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

BACKGROUND: There is evidence that pharmacist interventions improve clinical outcomes. The few studies that address economic outcomes (a) often report estimated instead of actual medical costs, (b) report only medication costs, or (c) have been conducted in settings that are not typical of community-based primary care. OBJECTIVES: To (a) determine whether a clinical pharmacist&#39;s recommen- dations to physicians regarding optimizing

The ability of children to recall highly stressful emotional events was investigated in a series of studies spanning more than a decade, and their findings are summarized here. The stressful events were injuries serious enough to require hospital ...

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient&#39;s physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize proce...

Background Despite the wide use of the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) in a clinical setting to assess agitated patients, a validation study to evaluate its psychometric properties was missing. Methods Data from the observational NATURA study were used. This research describes trends in the use of treatments in patients with acute psychotic episodes and agitation seen in emergency departments. Exploratory principal component factor analysis was performed. Spearman's correlation and regression analyses (linear regression model) as well as equipercentile linking of Clinical Global Impression of Severity (CGI-S), Agitation and Calmness Evaluation Scale (ACES) and PANSS-EC items were conducted to examine the scale's diagnostic validity. Furthermore, reliability (Cronbach's alpha) and responsiveness were evaluated. Results Factor analysis resulted in one factor being retained according to eigenvalue ≥1. At admission, the PANSS-EC and CGI-S were found to be linearly related, with an average increase of 3.4 points (p PANSS-EC for each additional CGI-S point. The PANSS-EC and ACES were found to be linearly and inversely related, with an average decrease of 5.5 points (p PANSS-EC for each additional point. The equipercentile method shows the poor sensitivity of the ACES scale. Cronbach's alpha was 0.86 and effect size was 1.44. Conclusions The factorial analyses confirm the unifactorial structure of the PANSS-EC subscale. The PANSS-EC showed a strong linear correlation with rating scales such as CGI-S and ACES. PANSS-EC has also shown an excellent capacity to detect real changes in agitated patients.

This chapter motivates the need for smarter interaction with a case study in healthcare that demonstrate the current state of interaction. The special challenges of practicing emergency medicine are reviewed, and a scenario is constructed to illustrate problems with current methods based on an observations study carried out at a hospital. A further scenario is then constructed showing how the problems that were observed may be avoided with smarter interaction. While the demonstrations of flawed interaction in this chapter only apply to ...

Lo scopo di questa tesi è analizzare il metodo attuale di soccorso e le successive complicazioni in un evento creato da un attentato terroristico o in cui siano coinvolte sostanze pericolose (Hazmat-CBRNe). In particolare, sarà seguito un percorso logico su come si dovrebbe effettuare un soccorso utilizzando un approccio olistico e omnicomprensivo, tenendo in considerazione tutte le variabili ed i pericoli. A questo scopo andrò a individuare un approccio progressivo, inizialmente spiegando la terminologia utilizzata e dei concetti fondamentali, in particolare per quello che riguarda tutti gli aspetti di pianificazione e prevenzione prima che un evento accada.  Seguirò con l’analisi di una scena del crimine e come si deve effettuare un soccorso corretto. In seguito analizzerò il fenomeno del terrorismo, poiché è una scena del crimine con nuovi pericoli. Infine tratterò il rischio CBRNe, in quanto, il terrorismo può utilizzare le armi non convenzionali per un attentato. Quest’ultimo capitolo approfondisce anche l’approccio al soccorso con presenza di sostanze pericolose, in quanto fino a indagini concluse, ci si deve relazionare sempre con una probabile scena del crimine, in questo caso anche contaminata. Come vedremo servirà lavorare approcciandosi con un metodo che tenga conto di tutto ciò, anche quando non si ha la certezza o la scena può evolvere. Attraverso dei “case study” e i fatti di cronaca reperiti attraverso un lavoro di “open source intelligence”, andrò ad analizzare le criticità e i punti deboli dell’attuale sistema del soccorso italiano anche per sottolineare la necessità per cui si adottano determinati protocolli e qual è il loro scopo. Vista la forte differenza con l’uso di terminologie e protocolli esteri, eviterò quanto più possibile l’uso e la descrizione del sistema italiano e di scenderne nel dettaglio, soprattutto perché la terminologia cambia in modo troppo radicale negli anni, e cambierà ancora nel futuro prossimo rendendo poco comprensibile questo lavoro tra qualche anno (oltre che distante dai fini di questa tesi). Come scelta tecnica quindi, ho deciso di adottare come linea di base il protocollo standard dell’ICS (Incident Command System) perché stabile nel tempo da decenni, e che ha una terminologia comune e conosciuta da moltissimi stati. Il nostro sistema riflette in buona parte il sistema ICS anche se con terminologie differenti. Utilizzare, la terminologia italiana (Es.: COC, COI, DICOMAC, ROS…) sarebbe di poca utilità a un lettore al di fuori del nostro Stato, e, tenendo anche in considerazione che il nostro sistema e la nostra terminologia sono sconosciuti alla maggior parte dei nostri stessi operatori, ho tentato di tenere il discorso quanto più semplice possibile e che possa essere una base di partenza per approfondire l’argomento.
Nel contesto italiano l’utilizzo della terminologia “anglofona” di questa tesi, ha un impatto limitato e trascurabile, in quanto, chi conosce il sistema sa facilmente riconoscere l’omologo italiano indipendentemente dalla evoluzione del nome e dalla normativa.

An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the &quot;gold standard&quot; for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in pa...

The aim of this case report was to demonstrate the importance of detailed clinical assessment in victims of attempted manual strangulation, to prevent the occurrence of delayed death due to an airway collapse; and to provide an update on clinical management of these patients. An elderly male patient presented with a sore throat and speech impairment after attempting manual strangulation. Physical examination showed reddish skin of the neck, an extensive haematoma of the hard palate and anterior tongue. Flexible laryngoscopy failed to show any swelling of the hypopharynx or larynx. A few hours after presentation, the patient developed acute dyspnoea and died. Autopsy and post-mortem CT scan showed a haematoma in the thyro-epiglottal space. In conclusion, victims of manual strangulation can survive despite internal neck injury which can lead to delayed fatal airway collapse. This is because often there are few or no signs of assault, therefore medical evaluation should be thorough and...

To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training.A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review.For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a “can-not-ventilate, can-not-intubate” situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills.