Procedural sedation is routinely performed for procedures in the emergency department (ED). Propofol is a commonly used sedative, frequently combined with an opioid or low-dose ketamine as an analgesic. However, there is still controversy on the optimal combination of agents in current guidelines. The objective of this systematic review is to identify and present studies comparing low-dose ketamine to opioids when combined with propofol for procedural sedation in the ED and to describe the dosing regimen, observed efficacy, and side effects. For this systematic review, following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, EMBASE and PubMed databases were searched. Studies comparing propofol with opioids versus propofol with low-dose (es)ketamine in patients undergoing procedural sedation for procedures in the ED were included. Analyses were descriptive because of the high heterogeneity among included studies. The outcomes were dosing regimen, efficacy of analgesia, efficacy of sedation depth, efficacy of recovery and (adverse) events. We included four out of 2309 studies found in the literature search. Overall, the studies had a low risk of bias, but the Grading of Recommendations Assessment, Development, and Evaluation evidence profile was downgraded due to the imprecision and inconsistency of the studies. All studies compared low-dose ketamine with fentanyl. Dosing ranged from 0.3 to 1.0 mg/kg (ketamine), 1.0-1.5 [mu]g/kg (fentanyl) and 0.4-1.0 mg/kg (propofol). The efficacy of analgesia was measured by two studies, one favoring the fentanyl group, and one favoring the ketamine group. The efficacy of sedation depth was measured by one study, with the fentanyl group having a deeper sedation score. Two studies showed shorter recovery time with low-dose ketamine. One study showed a higher incidence of cardio-respiratory clinical events and interventions in the fentanyl group. Two studies showed significant differences of overall sedation events in the fentanyl group. One study did not find any significant differences of the incidence of sedation events. This systematic review did not provide sufficient evidence that the combination of low-dose ketamine and propofol is associated with a shorter recovery time and fewer sedation events compared to the combination of opioids and propofol.

Carbon monoxide (CO) poisoning is one of the most common causes of poisoning death and its diagnosis requires an elevated carboxyhemoglobin (COHb) level. Noninvasive CO saturation by pulse oximetry (SpCO) has been available since 2005 and has the advantage of being portable and easy to use, but its accuracy in determining blood COHb level is controversial. To evaluate the accuracy of SpCO (index test) to estimate COHb (reference test). Systematic review and meta-analysis of diagnostic test accuracy (DTA) studies. Four electronic databases were searched (Medline, Embase, Cochrane Central Register of Controlled Trials, and OpenGrey) on 2 August 2022. All studies of all designs published since the 2000s evaluating the accuracy and reliability of SpCO measurement compared to blood COHb levels in human volunteers or ill patients, including children, were included. The primary outcome was to assess the diagnostic accuracy of SpCO for estimating COHb by blood sampling by modeling receiver operating characteristic (ROC) curves and calculating sensitivity and specificity (primary measures). The secondary measures were to calculate the limits of agreement (LOA) and the mean bias. This systematic review was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis-DTA 2018 guidelines and has been registered on International Prospective Register of Systematic Reviews (PROSPERO, CRD42020177940). The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Twenty-one studies were eligible for the systematic review; 11 could be included for the quantitative analysis of the primary measures and 18 for the secondary measures. No publication bias was found. The area under the summary ROC curve was equal to 86%. The mean sensitivity and specificity were 0.77, 95% confidence interval (CI, 0.66-0.85) and 0.83, 95% CI (0.74-0.89), respectively (2089 subjects and 3381 observations). The mean bias was 0.75% and the LOA was -7.08% to 8.57%, 95% CI (-8.89 to 10.38) (2794 subjects and 4646 observations). Noninvasive measurement of COHb (SpCO) using current pulse CO oximeters do not seem to be highly accurate to estimate blood COHb (moderate sensitivity and specificity, large LOA). They should probably not be used to confirm (rule-in) or exclude (rule-out) CO poisoning with certainty.

Alcohol use disorder (AUD) is chronic, lasting a person's lifetime. An increase in driving under the influence of alcohol, as well as emergency department (ED) visits, has been reported. The Alcohol Use Disorder Identification Test Consumption (AUDIT-C) is utilized to assess hazardous drinking. The Screening, Brief Intervention, Referral to Treatment (SBIRT) model assists in early intervention and referral for treatment. The Transtheoretical Model standardized instrument assesses individual readiness to change. These tools may be used by nurses and nonphysicians in the ED to help reduce alcohol use and the consequences of its use.

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BACKGROUND
The effect of early as compared with later initiation of direct oral anticoagulants (DOACs) in persons with atrial fibrillation who have had an acute ischemic stroke is unclear.

METHODS

We performed an investigator-initiated, open-label trial at 103 sites in 15 countries. Participants were randomly assigned in a 1:1 ratio to early anticoagulation (within 48 hours after a minor or moderate stroke or on day 6 or 7 after a major stroke) or later anticoagulation (day 3 or 4 after a minor stroke, day 6 or 7 after a moderate stroke, or day 12, 13, or 14 after a major stroke). Assessors were unaware of the trial-group assignments. The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days after randomization. Secondary outcomes included the components of the composite primary outcome at 30 and 90 days.

RESULTS
Of 2013 participants (37% with minor stroke, 40% with moderate stroke, and 23% with major stroke), 1006 were assigned to early anticoagulation and 1007 to later anticoagulation. A primary-outcome event occurred in 29 participants (2.9%) in the early-treatment group and 41 participants (4.1%) in the later-treatment group (risk difference, −1.18 percentage points; 95% confidence interval [CI], −2.84 to 0.47) by 30 days. Recurrent ischemic stroke occurred in 14 participants (1.4%) in the early-treatment group and 25 participants (2.5%) in the later-treatment group (odds ratio, 0.57; 95% CI, 0.29 to 1.07) by 30 days and in 18 participants (1.9%) and 30 participants (3.1%), respectively, by 90 days (odds ratio, 0.60; 95% CI, 0.33 to 1.06). Symptomatic intracranial hemorrhage occurred in 2 participants (0.2%) in both groups by 30 days.

CONCLUSIONS
In this trial, the incidence of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death at 30 days was estimated to range from 2.8 percentage points lower to 0.5 percentage points higher (based on the 95% confidence interval) with early than with later use of DOACs. (Funded by the Swiss National Science Foundation and others; ELAN ClinicalTrials.gov number, NCT03148457. opens in new tab.)

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BACKGROUND
Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations.

METHODS

We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome.

RESULTS
The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group.

CONCLUSIONS
Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457. opens in new tab.)

Improve and streamline the diagnostic decision-making process in emergency care. The newly revised third edition of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules offers an updated review of the evidence and expert discussion of relevant issues in diagnostic testing in the everyday practice of emergency medicine. This book also provides a detailed overview of the science of diagnostic testing and reviews the process behind the development of clinical decision rules. The focus is asking and answering practical questions using original research studies, while commenting on the best available evidence for relevant clinical topics.

Readers will also find:

- Comprehensive explorations of COVID-19, telemedicine, trauma, cardiology, infectious disease, and surgical and abdominal complaints.

- Practical discussions of urology, neurology, hematology, ophthalmology, pulmonology, rheumatology, and geriatric medicine.

- Exploration of practice and policy considerations of testing in an era of limited resources.

The book is perfect for emergency medicine physicians, nurses, and other allied health professionals. Readers of Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules, Third Edition will also earn a place in the libraries of administrators and managers in healthcare settings seeking to optimize the use of scarce resources while maintaining the highest standards of care.

For nearly 40 years, Rosen’s Emergency Medicine has provided emergency physicians, residents, physician assistants, and other emergency medicine practitioners with authoritative, accessible, and comprehensive information in this rapidly evolving field. The fully revised 10th Edition delivers practical, evidence-based knowledge and specific recommendations from clinical experts in a clear, precise format, with focused writing, current references, and extensive use of illustrations to provide definitive guidance for emergency conditions. With coverage ranging from airway management and critical care through diagnosis and treatment of virtually every emergency condition, from highly complex to simple and common, this award-winning, two-volume reference remains your #1 choice for reliable, up-to-date information across the entire spectrum of emergency medicine practice.

For nearly 40 years, Rosen’s Emergency Medicine has provided emergency physicians, residents, physician assistants, and other emergency medicine practitioners with authoritative, accessible, and comprehensive information in this rapidly evolving field. The fully revised 10th Edition delivers practical, evidence-based knowledge and specific recommendations from clinical experts in a clear, precise format, with focused writing, current references, and extensive use of illustrations to provide definitive guidance for emergency conditions. With coverage ranging from airway management and critical care through diagnosis and treatment of virtually every emergency condition, from highly complex to simple and common, this award-winning, two-volume reference remains your #1 choice for reliable, up-to-date information across the entire spectrum of emergency medicine practice.

For more than 30 years, the highly regarded Secrets Series® has provided students and practitioners in all areas of health care with concise, focused, and engaging resources for quick reference and exam review. Emergency Medicine Secrets, 7th Edition, offers practical, up-to-date coverage of the full range of essential topics in this dynamic field. This highly regarded resource features the Secrets' popular question-and-answer format that also includes lists, tables, pearls, memory aids, and an easy-to-read style - making inquiry, reference, and review quick, easy, and enjoyable.

Essential Med Notes is a clinical complement and resource for medical trainees. This 37th edition features substantial content revisions to the main text, figures, graphics, and evidence-based medicine boxes of all 31 chapters across the 3 volumes - Primary, Medicine, and Surgery.

Primary:
- Ethical, legal, and organizational medicine
- Anesthesia
- Clinical Pharmacology
- Dermatology
- Emergency medicine
- Family Medicine
- Medical Genetics
- Medical Imaging
- Pediatrics
- Psychiatry
- Public Health and Preventice Medicine

Aujourd'hui une large part des admissions aux urgences a pour origine une douleur abdominale aiguë non traumatique. Il s'agit alors de poser un diagnostic précis pour une prise en charge adaptée et rapide.

L'examen de référence des urgences abdominales aigues est la TDM. Il permet une étude très précise des lésions intra-abdominales, tant sur le plan morphologique que fonctionnel.

Le rôle du radiologue est donc primordial dans le diagnostic et la prise en charge du patient :
- évaluer le degré de gravité et donc d'urgence,
- confirmer/infirmer les diagnostics différentiels évoqués par la clinique et la biologie,
- et le cas échéant, relever un élément discriminant pour le choix de la technique opératoire choisie.

Cet ouvrage, de la collection Imagerie médicale pratique, contient toutes les connaissances nécessaires à l'interprétation des images TDM des principales pathologies de l'abdomen aigu.

Cet outil est conçu pour être pratique:
- la classification par pathologies des organes et par mécanismes physiologiques est didactique,
- les descriptions sémiologiques TDM sont simples et claires,
- les images privilégient les aspects typiques des pathologies,
- de nombreux encadrés avec des messages clés à retenir sont intégrés,
- ainsi que les items clés en fin de chaque sections.

Avec ce livre, vous avez toutes les clés en main pour un diagnostic rapide et efficace !

The sixth edition of this comprehensive yet conciseRosen & Barkin's 5 Minute Emergency Medicine Consultpulls together up-to-date and evidence-based practice guidelines for easy use in a busy emergency department. In just two brief, bullet-friendly, clutter-free pages, you can quickly decipher the information you need to confirm your diagnosis, order tests, manage treatment and more!Features new information—based on the latest practice guidelines and theoretical developments—and new approaches to diagnosis and management.Designed for integrating into your practice—in an urgent care setting with patients or during downtime between patients or meetings.Covers over 600 disease and condition topics, such as bleeding, orthopedic injuries, gastric conditions, domestic violence and more.Suitable for all practitioners, nurses and residents in an emergency room setting.Enrich Your Ebook Reading ExperienceRead directly on your preferred device(s),such as computer, tablet, or smartphone.Easily convert to audiobook,powering your content with natural language text-to-speech.

Ce guide, désormais incontournable de la pratique de la médecine aux urgences, aborde toutes les situations pathologiques sous un angle pratique et didactique.

Cette nouvelle édition a été considérablement augmentée. Après une première partie consacrée à l'organisation des structures d'urgence et à la prise en charge de la douleur, le praticien retrouvera les 145 situations cliniques prévalentes auxquelles ont été ajoutées une dizaine de nouvelles situations, que les évènements de ces dernières années ont rendu indispensables. Il s'agit en particulier des situations exceptionnelles. Pour chaque situation, le praticien retrouve sous forme de fiche la conduite à tenir fondée sur l'EBM et les recommandations actuelles, ainsi que les éléments de gravité et les éléments de surveillance.

La troisième partie, consacrée à la traumatologie s'est, elle aussi, vue étoffée de connaissances indispensables pour la pratique quotidienne. Une analyse radiologique membre par membre, région par région détaillant les bonnes pratiques, critères de qualité et grille de lecture vient compléter les fiches déjà exhaustives des traumatismes.

Et enfin, l'ouvrage est complété par une abondante documentation disponible en ligne. En effet, le lecteur dispose de plus de 500 documents, dont notamment tous les textes légaux et toutes les recommandations qui rythment sa pratique, ainsi qu'une imagerie (radios, TDM, photos, vidéos, etc.) qui viendra illustrer chacune des situations abordées.