Acute traumatic wounds: evaluation, cleansing, and repair in the ED.

Traumatic wounds are a common presentation in the emergency department. While most minor traumatic wounds and lacerations will heal well, appropriate management is required to preserve function and cosmesis as well as to prevent infection and other complications. This supplement reviews evidence-based recommendations for management of acute traumatic wounds, including evaluation, cleansing, anesthesia, selection of closure methods and materials, and post-repair instruction. Management of high-risk wounds and special considerations for the evaluation and repair of facial lacerations are also reviewed.

Massive Gastrointestinal Hemorrhage.

Massive gastrointestinal hemorrhage is a life-threatening condition that can result from numerous causes and requires skilled resuscitation to decrease patient morbidity and mortality. Successful resuscitation begins with placement of large-bore intravenous or intraosseous access; early blood product administration; and early consultation with a gastroenterologist, interventional radiologist, and/or surgeon. Activate a massive transfusion protocol when initial red blood cell transfusion does not restore effective perfusion or the patient's shock index is greater than 1.0. Promptly reverse coagulopathies secondary to oral anticoagulant or antiplatelet use. Use thromboelastography or rotational thromboelastometry to guide further transfusions. Secure a definitive airway and minimize aspiration.

The transmission of the influenza virus from patient to emergency physician: No flu for you.

BACKGROUND: Significant morbidity and mortality is attributed to infection with the influenza virus annually and care is often sought in Emergency Departments (ED). The exposure of Emergency Department healthcare personnel and subsequent illness is speculated to be high but has not been quantified. METHODS: All physicians and mid-level providers in a large tertiary care ED who cared for an Influenza-positive patient were identified and surveyed. Information was gathered regarding each provider's report of an Influenza-like illness during the study period as well as laboratory testing results, sick contacts and subsequent missed work. General descriptive information of Influenza-positive patients was extracted through a retrospective chart review. RESULTS: 1020 Influenza-positive patients were cared for by 106 physicians and advanced practice nurses. Patients testing positive for Influenza-A were more likely to be admitted (p = .003). The majority of patients (83%) were cared for by an attending only. Our provider survey response rate was 87%. 1 in 4 providers reported suffering from an Influenza-like illness during the study period and no providers subsequently missed work days. Only 4 (5%) of those providers sought medical care to receive testing. Overall, 2% of ED providers tested positive for Influenza. CONCLUSIONS: Among Emergency Department providers, transmission of clinically significant Influenza illness was low.

An Unusual Consolidation: Lobar Pulmonary Hemorrhage Due to Antithrombotic Therapy.

Alveolar hemorrhage is a rare yet devastating clinical entity if not identified and treated aggressively. Exceedingly rare are the cases of anticoagulant-induced alveolar hemorrhage with very few cases described in the current literature. The nonspecific presentation of an alveolar hemorrhage makes its diagnosis and appropriate treatment difficult in the emergency department. We report a case of a patient on warfarin for atrial fibrillation who was initially misdiagnosed as having community-acquired pneumonia, but subsequently was identified to have a fatal alveolar hemorrhage.

The Massachusetts Emergency Medical Service Stroke Quality Improvement Collaborative, 2009-2012.

INTRODUCTION: Quality improvement collaboratives are a popular model used to address gaps between evidence-based practice and patient care. Little is known about use of such collaboratives in emergency medical services, particularly for improving prehospital stroke care. To determine the feasibility of using this approach to improve prehospital stroke care, we conducted a pilot study of the Emergency Medical Services Stroke Quality Improvement Collaborative. METHODS: Seventeen Massachusetts emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified 5 prehospital stroke performance measures to assess the quality of prehospital care, guide collaborative activities, and monitor change in performance over time. During learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Focus groups were conducted to understand participants' experiences with the collaborative. RESULTS: Participating emergency medical service agencies collected stroke performance measures on 3,009 stroke patients during the pilot study. Adherence to 4 of 5 performance measures increased significantly over time. Participants acknowledged that the collaborative provided them with an efficient and effective framework for stroke quality improvement and peer-learning opportunities. CONCLUSION: As evidenced in Massachusetts, quality improvement collaboratives can be an effective tool to improve prehospital stroke care. The data collected, improvements made, participation of emergency medical service agencies, and positive experiences within the collaborative support the continued use of this approach.