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A common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days.
This was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound.
Of the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram.
Next-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.
The primary objective was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture.
This was a retrospective chart review of patients ages 65 years and older presenting to one of two academic EDs with a discharge diagnosis of a hip fracture from January 1, 2014, to December 31, 2015. A multivariable logistic regression analysis was used to determine variables independently associated with the development of acute in-hospital delirium within 72 hours of ED arrival.
Of the 668 included patients, 181 (27.1%) developed delirium within 72 hours of ED arrival. History of neurodegenerative disease or dementia (odds ratio [OR]: 5.7, 95% confidence interval [CI]: 3.9, 8.4), age > 75 (OR: 2.8, 95% CI: 1.4, 5.6), and absence of analgesia (no opioid or nerve block) in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with the development of acute in-hospital delirium; 525 (78.6%) patients received opioid analgesia in the ED. The most common analgesics used in the ED were intravenous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED.
Advanced age and signs of dementia or neurodegenerative disease are predictors of 72-hour delirium that can be screened for during triage. Improved pain control in the ED may reduce the risk of acute in-hospital delirium.
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