Emergency Department Visits by Pediatric Patients for Snakebites.

OBJECTIVES: Few studies have examined pediatric emergency department (ED) visits for snakebites. This study sought to examine characteristics of pediatric patients presenting to EDs nationally in the United States for snakebites. METHODS: This retrospective cohort study obtained data from the Nationwide Emergency Department Sample for 2006 to 2014. Pediatric patients sustaining a snakebite were identified with International Classification of Diseases, Ninth Revision, E-codes E905.0 or E906.2. Data extracted included age, sex, insurance, disposition, hospital trauma designation, ED charges, and geographic region. Comparative analyses were performed for patients younger than 10 years and aged 10 to 17 years. RESULTS: There were 24,388 ED visits from 2006 to 2014 by pediatric patients for snakebites: 10,554 were younger than 10 years, and 13,834 were aged 10 to 17 years. Males comprised 62% and 67% of the respective age cohorts. Most patients (younger than 10 years, 68%; aged 10-17 years, 63%) experienced snakebites in the South. Only 14% of those younger than 10 years and 10% of those aged 10 to 17 years were treated at a level 1 trauma center, whereas 50% and 54%, respectively, were treated at hospitals with no trauma designation. The majority of patients were discharged from the ED (younger than 10 years, 72%; aged 10-17 years, 80%). The mean ED charges for snakebite victims younger than 10 years were $5363 and for those aged 10 to 17 years were $4618. Medicaid was the primary insurer of younger patients, whereas private insurance was more common in older patients. CONCLUSIONS: Most pediatric snakebites are seen in nontrauma centers and in the South region and are more commonly male. Most patients were discharged from the ED, with a small percentage being admitted or transferred to another facility.

Coexistence of Substance Abuse among Emergency Department Patients Presenting with Suicidal Ideation.

BACKGROUND: Patients who are suicidal commonly seek care in the emergency department (ED). Few studies have examined the coexistence between suicidal ideation, substance abuse, and psychiatric diagnosis. OBJECTIVES: This study sought to determine how often suicidal ED patients have coexisting substance abuse and psychiatric diagnosis in addition to describing the characteristics of target population. METHODS: In this retrospective cohort study, chart reviews were conducted of patients over 12 with suicidal ideation who presented to an academic ED from October 2016 to March 2017. Data abstracted included gender, age, insurance, prior psychiatric diagnoses, substances abused, presence of a suicide attempt, prior suicidality, number of ED visits in the prior year, and disposition. Both descriptive and inferential statistics were calculated. RESULTS: There were 427 patient visits to the ED for suicidality during the study period, of which 54% were male, with a mean age of 34 years. Most patients (92%) had a psychiatric diagnosis, most commonly depression (67%). More than one psychiatric diagnosis was reported in 51% of patients, while 8% had no reported underlying psychiatric diagnosis. Substance abuse was reported in 58% of patients, including marijuana (42%) and opioids (41%). Polysubstance abuse was reported in 42%. Approximately half of the patients had three or more ED visits in the previous 12 months. Most patients were insured by Medicaid (51%), while 59% were admitted for inpatient treatment. CONCLUSION: Substance abuse and psychiatric diagnosis were reported frequently among patients presenting to the ED with suicidal ideation, often involving more than one substance/diagnosis. Future studies should be aimed at evaluating the relationship between these conditions and determining how to better care for this population.

Adult Ileocolic Intussusception from the Appendix.

Intussusception is more commonly considered in the pediatric patient with abdominal pain, but can occur in adults as well. Adult patients are more likely to have an underlying intra-abdominal pathology leading to the condition. We present an adult patient presenting with abdominal pain with ileocecal intussusception diagnosed on imaging and confirmed surgically. In this case, appendiceal pathology served as the lead point for the intussusception.

Characteristics and Management of Emergency Department Patients Presenting with C2 Cervical Spine Fractures.

BACKGROUND: C2 cervical fractures account for approximately 18% of cervical spine injuries. Few studies have examined patients presenting to an emergency department (ED) with this injury relative to demographics, injury mechanism, and hospital course. OBJECTIVES: To compare multiple variables of ED patients presenting with these types of injuries. METHODS: In this retrospective cohort study, data were obtained from the Trauma Registry of an academic trauma referral center from January 1, 2011, to December 31, 2015. Patients who presented with a C2 fracture were identified. Information regarding the patient's gender, age, mechanism of injury, associated injuries, if a procedure was required, disposition, and mortality was extracted. Comparative analyses were conducted between cases over or under age 60. RESULTS: Between January 1, 2011, to December 31, 2015, a total of 139 patients with C2 fractures were identified. Most patients were 60 years or older (79%). Of those, 62% were female, and falls were the most common mechanism (78%). Of those under 60, 50% were female and motor vehicle crashes (MVCs) were the most common mechanism (71%). Odontoid fractures comprised 84% of C2 fractures. Only 6% had an associated spinal cord injury. Less than one-third of patients required operative intervention for their spinal injuries, and intervention was more common in older patients. Following admission, 19% of patients required placement into a nursing home or skilled nursing facility. CONCLUSIONS: C2 fractures are more common in older adults and usually resulted from falls. Odontoid fractures are most common. Most C2 fractures do not result in neurologic injury, and only a third were treated surgically. However, several patients were unable to return to their homes following their injury.

Emergency Department Visits for Sexual Assault by Emerging Adults: Is Alcohol a Factor?

INTRODUCTION: Emerging adults (18-25 years of age) are at increased risk for sexual assault. There is little Emergency Department (ED) data on sexual assaults that involve alcohol among this population. The purpose of this study was to analyze ED visits for sexual assault and determine if alcohol consumption by the patient was noted. METHODS: This study was a retrospective chart review of patients aged 18-25 presenting to an ED in a college town over a four-year period. Extracted variables included age, gender, delay in seeking care, sexual assault nurse examiner (SANE) evaluation, and alcohol consumption by the patient. For analysis of alcohol use, cases were categorized as ages < 21 and ≥ 21. RESULTS: There were 118 patients who presented to the ED from 2012 to 2015. The mean age of the cohort was 20 years, and almost 70% of visits were among those < 21. Of those aged < 21, 74% reported alcohol consumption, in contrast to 48% of those ≥ 21 (p = 0.055). Of those reporting alcohol use, 36% were evaluated on the day of the assault compared to 61% of those not reporting alcohol (p=0.035). CONCLUSION: This study found that ED visits for sexual assault in emerging adults were more common in younger patients. Alcohol use occurred more frequently with patients under the legal drinking age, and presentation was also more likely to be delayed. The relationship between sexual assault and alcohol use should underscore primary prevention efforts in emerging adult populations.

Takotsubo Cardiomyopathy in the Emergency Department: A FOCUS Heart Breaker.

Takotsubo cardiomyopathy (TCM) is an important condition for the emergency physician to consider in patients with cardiovascular symptoms. A 70-year-old woman presented with chest pain and nausea following emotional trauma. She had an elevated troponin and a normal electrocardiogram with no history of previous cardiac disease. Point-of-care focused cardiac ultrasound (FOCUS) showed reduced left ventricular systolic function with mid to apical hypokinesis. Cardiac catheterization revealed clean coronary arteries and confirmed the suspected diagnosis of TCM. Few reports emphasize the importance of FOCUS in the diagnosis and management of TCM in the emergency department. We detail FOCUS findings that assisted with diagnosis of TCM and describe how this quick, noninvasive imaging modality can be used to assess and manage emergent conditions.

Emergency department visits for work-related injuries.

BACKGROUND: Work-related injuries are commonly seen in the emergency department (ED). This study sought to analyze characteristics of ED patient visits that were billed under workers' compensation. METHODS: This was a retrospective chart review of visits during 2015 that were billed under workers' compensation at an academic ED. The following variables were collected: age, gender, mechanism of injury/exposure, diagnoses, imaging performed, specialty consultation, operative requirement, follow-up specialty, and ED disposition. RESULTS: In 2015, 377 patients presented to the ED for work-related injuries. The most common mechanism of injury was fall. Frequent diagnoses included lower extremity injuries and hand/finger injuries. The most common consulting service was orthopedics. Only five patients were referred to occupational medicine for follow up. CONCLUSION: Knowledge of the types of occupational injuries and subsequent care required may help guide both workers and employers how to best triage patients within the healthcare system. Alternative settings such as occupational medicine or primary care services may be appropriate for some patients.

Emergency department visits coded for swimming pool diving injuries.

Despite legislative efforts to enhance safety in public swimming pools, diving injuries are still common. This study investigated the characteristics of emergency departments (EDs) visits for diving accidents. This study utilized 2006-2014 data from the Nationwide Emergency Department Sample and examined visits for accidents due to diving or jumping into water (swimming pool). Data were stratified by age categories. Over 83,000 ED visits were found and the majority of visits were by males. Significantly more patients were in the 15-24 age category. The majority of patients were discharged and were covered by private insurance. Total charges for the six-year period approached $620 million. Spinal cord injuries were more common in those over age 25, whereas intracranial injuries occurred more frequently in younger patients. This study provides a profile of patients presenting to US EDs for diving-related injuries.

Emergency department visits by pediatric patients sustained as a passenger on a motorcycle.

OBJECTIVE: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle. METHODS: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges. RESULTS: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries. CONCLUSION: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.

Violence in the Emergency Department: A Global Problem.

Violence against health care workers is an unfortunately common event. Because of several inherent factors, emergency departments are particularly vulnerable. Once an incident occurs, it often goes unreported and leads to both physical and mental trauma. Health care workers should learn to recognize the cues that patients are escalating toward violence and be familiar with various options for sedating agitated patients. If sedation is not successful, physical restraint may become necessary. There are measures that can be taken that may help minimize the likelihood of violence toward health care workers. These measures include legislation, physical design, and increased security.

Emergency department visits by pediatric patients for poisoning by prescription opioids.

BACKGROUND: Prescription medication abuse is an increasingly recognized problem in the United States. As more opioids are being prescribed and abused by adults, there is an increased risk of both accidental and intentional exposure to children and adolescents. The impact of pediatric exposures to prescription pain pills has not been well studied. OBJECTIVES: We sought to evaluate emergency department (ED) visits for poisoning by prescription opioids in pediatric patients. METHODS: This retrospective study looked at clinical and demographic data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2012. RESULTS: There were 21,928 pediatric ED visits for prescription opioid poisonings and more than half were unintentional. There was a bimodal age distribution of patients, with slightly more than half occurring in females. The majority of patients were discharged from the ED. More visits in the younger age group (0-5 years) were unintentional, while the majority of visits in the adolescent age group (15-17 years) were intentional. Mean charge per discharge was $1,840 and $14,235 for admissions and surmounted to over $81 million in total charges. CONCLUSION: Poisonings by prescription opioids largely impact both young children and adolescents. These findings can be used to help target this population for future preventive efforts.

A 5-year comparison of ED visits by homeless and nonhomeless patients.

BACKGROUND: A 2005 study examined emergency department (ED) utilization by homeless patients in the United States. Within the following 5 years, unemployment increased by 5%. OBJECTIVE: The objective was to analyze changes in ED utilization between 2005 and 2010 by homeless patients and compare with nonhomeless visits. METHODS: Data from the 2010 National Hospital Ambulatory Medical Care Survey were evaluated. RESULTS: Approximately 679854 visits were made by homeless patients, the majority of which were made by men (72.3%) and patients between the ages of 45 and 64 (50.5%). Homeless patients were twice as likely to be uninsured. ED visits by homeless patients had increased by 44% during the 5-year period. Arrival to the ED by ambulance increased by 14% between the study years, and homeless patients were less likely to be admitted. CONCLUSION: The number of visits by homeless patients in the ED increased proportionally to an overall increase in ED visits between 2005 and 2010.

Emergency Visits for Prescription Opioid Poisonings.

BACKGROUND: Prescription opioid abuse and overdose has steadily increased in the United States (US) over the past two decades, and current research has shown a dramatic increase in hospitalizations resulting from opioid poisonings. Still, much is unknown about the clinical and demographic features of patients presenting to emergency departments (EDs) for poisoning from prescription drugs. OBJECTIVE: We sought to evaluate ED visits by adults for prescription opioids. METHODS: This was a retrospective cohort study utilizing 2006-2011 data from the Nationwide Emergency Department Sample. Total number of admissions (weighted), disposition, gender, age, expected payer, income, geographic region, charges, and procedures performed were examined. RESULTS: From 2006 through 2010, there were 259,093 ED visits by adults for poisoning by opioids, and 53.50% of these were unintentional. The overall mean age of patients was 45.5 years, with more visits made by females (52.37%). Patients who unintentionally overdosed were more likely to have Medicare (36.54%), whereas those who intentionally overdosed had private insurance (29.41%). The majority of patients resided in the South (40.93%) and came from lower-income neighborhoods. Approximately 108,504 patients were discharged, and 140,395 were admitted. CONCLUSIONS: There were over 250,000 visits to US EDs from 2006 through 2011 with a primary diagnosis of poisoning by a prescription opioid. Females made the majority of visits, and over half were admitted to the hospital, resulting in over $4 billion in charges. Future studies should examine preventative measures, optimal screening, and intervention programs for these patients.

Visits by the elderly to United States EDs for alcohol-related disorders.

OBJECTIVES: The objectives are to estimate the number of elderly patients presenting to emergency departments (EDs) in the United States from 2006 to 2011 for alcohol-related disorders and examine their demographic and clinical features. METHODS: This study used 2006 to 2011 data from the Nationwide ED Sample, a stratified, multistage sample designed to give national estimates of US ED visits each year. Clinical Classifications Software 660 code ("alcohol-related disorders") was used. The clinical and demographic features that were examined were as follows: number of admissions, disposition, sex, age, expected payer, income, geographic region, charges, and primary diagnoses and procedures performed. RESULTS: From 2006 to 2011, there were 1620345 ED visits for alcohol-related disorders in elderly patients. Roughly one-third were discharged from the ED, whereas 66% (1078677) were admitted to the hospital. Approximately 73% were male, and the mean age was 73 years. Most patients used Medicare (84%), resided in neighborhoods with the lowest median income national quartile (29%), and lived in the South (36.4%). The average charge for discharged patients was $4274.95 (4050.30-4499.61) and $37857.20 (36813.00-38901.40) for admitted patients. The total charges for all patients treated and released from the ED were $2166082965.40 and admitted was $40835690924.40. CONCLUSIONS: This study provided insight not only into the sociodemographic characteristics of this patient population but also the health care costs related to alcohol-related ED visits. These results may contribute to the development of future interventions targeted toward this population.

Pediatric visits to United States Emergency Departments for alcohol-related disorders.

BACKGROUND: The use of alcohol by pediatric patients has not been thoroughly examined in the United States (US). Patients with complaints related to alcohol use frequently present to the Emergency Department initially. OBJECTIVE: Our aim was to determine the number of pediatric patients (ages 17 years and younger) presenting to Emergency Departments (EDs) in the US from 2006 to 2008 for alcohol-related disorders and examine selected clinical and demographic features of this population. METHODS: This was a retrospective cohort study using 3 years (2006-2008) of data from the Nationwide Emergency Department Sample. This database was used to identify patients younger than 18 years of age with an alcohol-related ED visit, and clinical and demographic features were examined. RESULTS: From 2006 to 2008, a total of 218,514 pediatric patients presented to US EDs and received a subsequent diagnosis of an alcohol-related disorder. Mean age of patients was 15.61 years. Most patients were male and tended to be from higher-income communities. CONCLUSIONS: There were 218,514 visits to US EDs by patients younger than 18 years of age for alcohol-related disorders, accounting for >$850 million dollars in charges. ED-based brief alcohol interventions shown to work in adult populations should be explored for use in pediatric patients.

Falls and dilemmas in injury prevention in older West Virginians.

UNLABELLED: Falls are the number one cause of injury-related morbidity and mortality in West Virginia senior citizens. Poor outcomes following falls are exacerbated by numerous comorbidities which are prevalent in the elderly population in West Virginia. This study describes the injury patterns, resource utilization and dispositions of WV seniors injured in a fall. METHODS: This is a descriptive retrospective cohort study utilizing the West Virginia State Trauma System registry; which collects trauma data from 33 acute care facilities in West Virginia. RESULTS: Data from 5498 cases were reviewed for patients enrolled in the Registry in 2010. Fall victims aged 65 and older were included. Most falls occurred in the home (75.2%) or in a residential institution (11.3%). Femur fractures (36.3%) and intracranial hemorrhages (8.2%) were the most common injury diagnoses. Disposition back home declined from 58.6% in the 60-65 age group to 20.9% returning home following falls in the age 90-94 group. Conversely, disposition to a skilled nursing facility rose from 20.1% in the age 60-65 group to 49.1% in the age 90-94 group. The case fatality rate for all the seniors enrolled in the trauma system was 3.3%. DISCUSSION: Fall was the mechanism of injury for 83.3% of traumatic injuries in persons over the age of 65 enrolled in the WV trauma system. Older West Virginians suffer from numerous comorbidities that increase the risk of fall as well as the severity of injuries from a fall. CONCLUSION: In West Virginia, there is a correlation between increasing age and less desirable outcomes and dispositions from trauma centers for senior citizens after a fall. West Virginia patients, families and care providers must frequently face complicated treatment dilemmas, especially as the related risk of falling and the co-morbid conditions are commonly seen in older West Virginians. Multi-modal fall prevention programs can reduce the risk of falls in senior citizens.

Hospitalizations of older patients with human immunodeficiency virus in the United States.

BACKGROUND: Older adults represent a growing percentage of the United States (US) population living with human immunodeficiency virus (HIV). The Emergency Department plays an integral role in the identification and initial evaluation and treatment of patients with HIV. OBJECTIVE: We sought to estimate the number of hospitalizations of older adults (age ≥ 50 years) with HIV in the United States from 2000 to 2006 and compare features of this population to younger adults with HIV. Clinical and demographic characteristics of the younger cohort (19-49 years) and two older cohorts (ages 50-64 and ≥ 65 years) were examined and compared. METHODS: Data from the Nationwide Inpatient Sample was used to compare the three groups of HIV-positive patients. Comparisons between the most common discharge diagnoses and primary procedures were also made. RESULTS: Older adults with HIV constitute almost one quarter of the hospitalizations of adults with HIV. Older adults with HIV were more likely to be male, have a significantly higher average hospital charge, and have a longer length of stay than younger adults with HIV. Pneumonia and fluid and electrolyte disorders were common diagnoses among all three age cohorts. CONCLUSIONS: Older HIV patients were more likely to die during hospitalization compared with younger adults with HIV and older adults without HIV. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the current HIV population or new infections.

A comparison of National Emergency Department use by homeless versus non-homeless people in the United States.

BACKGROUND: A single-site study described differences between homeless and non-homeless patient utilization of the emergency department (ED). No prior study has examined ED use by the homeless on a national level. OBJECTIVE: To analyze national ED utilization by homeless patients. METHODS: Data were extracted from the 2005 National Hospital Ambulatory Medical Care Survey. SAS callable SUDAAN was used to produce national estimates. Results. Of the 115 million visits to national EDs in 2005, 472,922 were made by homeless patients. In comparison with the non-homeless, these patients were more likely to arrive by ambulance and to be uninsured. Both groups had similar admission rates and triage urgency, with a trend toward increased diagnostic testing for homeless patients. CONCLUSION: Homeless patients who visited EDs in 2005 were more likely to arrive by ambulance despite similar triage urgency and admission rates compared with the non-homeless, and were less likely to be insured.

Emergency medical services-based community stroke education: pilot results from a novel approach.

BACKGROUND AND PURPOSE: Although previous studies using mass media have demonstrated successful public stroke awareness campaigns, they may have been too costly for smaller communities to implement. The goal of this study was to investigate if a novel emergency medical services (EMS) -sponsored community awareness campaign could increase public stroke awareness. METHODS: This was a pre- and postintervention study with 2 phases conducted between August 2005 and July 2007. During Phase I, strategic placement of stroke education media by EMS personnel was implemented in one county over a 2-year period. Five random-digit, standardized phone surveys measuring stroke awareness were conducted with county residents to assess the campaign's impact. In Phase II, EMS interventions and random-digit measurements were conducted in 4 additional counties with 4 counties randomly selected as controls. RESULTS: A pattern of increasing stroke knowledge after exposure to the EMS intervention followed by declines in the absence of the intervention was observed during Phase I. EMS interventions also demonstrated a positive effect on the stroke knowledge of residents who lived in counties exposed to the intervention during Phase II with a statistically significant (P<0.05) increase observed in the proportion of respondents that named 2 stroke risk factors and 3 symptoms in comparison to either no changes or declines in the control counties. No evidence of a positive impact on knowledge of calling 911 for stroke was observed. CONCLUSIONS: Results of this study suggest that the public's knowledge of stroke signs and symptoms was increased using communitywide EMS-based programs. Additional studies are needed to determine optimal methods for educating the public regarding the need to call 911 for stroke and to confirm these results in other locales.

All-terrain vehicle-related hospitalizations in the United States, 2000-2004.

OBJECTIVES: To estimate the incidence of all-terrain vehicle (ATV)-related injury hospitalizations in the United States from 2000 through 2004, and to describe the types of injuries and associated hospital costs for the entire population. METHODS: Data for 2000 through 2004 were obtained from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample--a stratified probability sample of 1004 community hospitals from 37 states. ATV injuries were defined by ICD-9-CM external cause of injury codes within E821. Variables included age, gender, primary diagnoses, patient disposition, primary payer, and hospital charges. Data were analyzed in 2007. RESULTS: There were an estimated 58,254 ATV-related hospitalizations, increasing 90% over the 5-year period. Eighty percent were men. Thirty percent of the cases involved youth under age 18, and 8% were over age 60. Passengers accounted for 9% of the hospitalizations. Eighty-five percent were routinely discharged to home while 13% required long-term rehabilitation or home health care. Payers included private insurance (62%), Medicaid/Medicare (19%), and self-pay (12%). Rural hospitals treated 23% of the cases and urban teaching hospitals 47%. Estimated total hospital charges were about $1.1 billion (20% paid from public funds) with an average charge per patient of $19,671. Leading injuries included fractures of lower limbs (22%; mean hospital charges of $19,626), other fractures (15%; $18,873), and intracranial injuries (14%; $26,906). The overall hospital admission rate was 4.4 per 100,000 population with variation by year, gender, and age. CONCLUSIONS: Voluntary industry and government safety efforts have had little impact on the increasing incidence and cost of ATV injuries. Renewed prevention efforts to making ATV riding safer are warranted.