Current Issue : July - September Volume : 2016 Issue Number : 3 Articles : 4 Articles
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated\nwith significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of\nparenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the\nmost common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window,\nunpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome\nthese disadvantages, direct-acting oral anticoagulants (DOACs)ââ?¬â?dabigatran, rivaroxaban, apixaban, and edoxabanââ?¬â?have been\ndeveloped for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE.\nAdvantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In\nclinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention\nof VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the\npractical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring,\nanticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements\nand antidotes, are also discussed...
Background: Progression from nonsevere sepsisââ?¬â?i.e., sepsis without organ failure or shockââ?¬â?to severe sepsis or\nshock among emergency department (ED) patients has been associated with significant mortality. Early recognition\nin the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes.\nWe sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic\nshock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis.\nMethods: This is a retrospective cohort of patients presenting to a single urban academic ED from November 2008\nto October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the\nED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure\n<90 mmHg upon triage, an initial whole blood lactate level ââ?°Â¥4 mmol/L, or one or more of a set of predefined signs of\norgan dysfunction upon initial assessment. Disease progression was defined as the development of any combination\nof the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on\npredefined potential predictors of disease progression and outcome measures of disease progression were collected\nby a query of the electronic medical record and via chart review. Logistic regression was used to assess associations\nof potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension,\nor death.\nResults: In this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial\nserum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40ââ?¬â??9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED\ntriage (OR 4.59; 95 % CI 1.57ââ?¬â??13.39; p < 0.01) were independently associated with disease progression to severe sepsis\nor shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation.\nConclusions: In our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg\nindependently predict early progression to severe sepsis or shock among ED patients with presumed sepsis....
Background: Patients with a presumed diagnosis of acute coronary syndrome (ACS) or stroke may have had\ncontact with several healthcare providers prior to hospital arrival. The aim of this study was to describe the various\nprehospital paths and the effect on time delays of patients with ACS or stroke.\nMethods: This prospective observational study included patients with presumed ACS or stroke who may choose\nto contact four different types of health care providers. Questionnaires were completed by patients, general\npractitioners (GP), GP cooperatives, ambulance services and emergency departments (ED). Additional data were\nretrieved from hospital registries.\nResults: Two hundred two ACS patients arrived at the hospital by 15 different paths and 243 stroke patients by\nten different paths. Often several healthcare providers were involved (60.8 % ACS, 95.1 % stroke). Almost half of all\npatients first contacted their GP (47.5 % ACS, 49.4 % stroke). Some prehospital paths were more frequently used,\ne.g. GP (cooperative) and ambulance in ACS, and GP or ambulance and ED in stroke. In 65 % of all events an\nambulance was involved. Median time between start of symptoms and hospital arrival for ACS patients was over\n6 h and for stroke patients 4 h. Of ACS patients 47.7 % waited more than 4 h before seeking medical advice\ncompared to 31.6 % of stroke patients. Median time between seeking medical advice to arrival at hospital was\nshortest in paths involving the ambulance only (60 min ACS, 54 min stroke) or in combination with another\nhealthcare provider (80 to 100 min ACS, 99 to 106 min stroke).\nConclusions: Prehospital paths through which patients arrived in hospital are numerous and often complex,\nand various time delays occurred. Delays depend on the entry point of the health care system, and dialing the\nemergency number seems to be the best choice. Since reducing patient delay is difficult and noticeable differences\nexist between various prehospital paths, further research into reasons for these different entry choices may yield\npossibilities to optimize paths and reduce overall time delay....
Theimportance of early access to prehospital care has been demonstrated in many medical emergencies. This work aims to describe\nthe potential time benefit of implementing a student Community First Responder scheme to support ambulance services in an\ninner-city setting in the United Kingdom. Twenty final and penultimate year medical students in the UK were trained in the ââ?¬Å?First\nPerson on Sceneââ?¬Â Business and Technology Education Council (BTEC) qualification. Over 12 months, they attended 89 emergency\ncalls in an inner-city setting as Community First Responders (CFRs), alongside the West Midlands Ambulance Service, UK. At\nthe end of this period, a qualitative survey investigated the perceived educational value of the scheme. The mean CFR response\ntime across all calls was an average of 3 minutes and 8 seconds less than ambulance crew response times. The largest difference\nwas to calls relating to falls (12 min). The difference varied throughout the day, peaking between 16:00 and 18:00. All questionnaire\nrespondents stated that they felt more prepared in assessing and treating acutely unwell patients. In this paper, the authors present\na symbiotic solution which has both reduced time to first on scene and provided training and experience in medical emergencies\nfor senior medical students....
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