The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available ...literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.
ABSTRACT
Introduction
A commercially available snake bite device was pilot tested for novel use as a method of hemostasis and wound repair at a noncompressible site in a live swine model. The device ...is light, is plastic, uses a hook-and-loop strap attachment, and is easily deployed. The device could offer a method for the field repair of an actively bleeding laceration at a noncompressible site in an austere environment.
Materials and Methods
This was an interventional, prospective, controlled study in a large animal model. The study was approved by the Rhode Island Hospital Institutional Review Board (IRB) and the Animal Welfare Committee/Institutional Animal Care and Use Committee and the Lifespan Research Conflict of Interest Committee. Each animal acted as its own control. Blood loss was measured and compared between repairs of standardized incisions with and without the device’s application. The lacerations were sutured closed. Two proceduralists alternated tasks of wound repair versus blood collection. Blood loss was measured by using gauze sponges to capture the blood during a 30-second free-bleeding period and during the repair itself. Using a one sample t-test (the expected difference in blood loss between the two incision repair methods = 0 if the null hypothesis were true), we calculated the mean difference in the deltas between the repair methods.
Results
The mean delta difference was 3.1 g (SE ± 0.97). The t-test demonstrated that there was a significantly greater blood loss during the standard repair method, t(9) = 3.11, P < 0.01 than during the repair with the device in place (see Fig. 2). A statistical power analysis conducted showed that with a sample size of 10 animals, there was sufficient statistical power to detect this significant effect (β = 0.82, α < 0.05, one-tailed).
FIGURE 2.
Blood loss results.
30s = free blood loss for 30 seconds after incision before repair, by group (control versus device). Repair blood loss = blood loss during repair by group (control versus device).The 30-s blood loss showed no statistically significant difference, demonstrating similar baseline bleeding rates between groups.The repair blood loss showed a statistically significant difference between groups; less blood loss with the device’s application.
Conclusions
There was statistically significantly less blood loss during the repairs with the device’s application. This feasibility experiment demonstrates that a commercially available snakebite device may be useful for hemostasis during laceration repair at anatomic sites not amenable to application of tourniquets or compressive dressings. Strengths of the study include the prospective controlled design, including the use of each animal as its own control; alternating proceduralists to account for any variability in suturing efficiency; and the statistical significance of the results despite the small number of subjects. One weakness is that the time required for each repair was not measured. The device’s portability and reusability suggest applicability in austere medical environments. Future studies could include timing the repairs, using a skin stapler or wound adhesive instead of sutures, applying a hemostatic agent before the repair, and sequentially applying the device to wounds longer than the device.
Abstract
Objectives
Patients with acute bleeding are frequently transfused with emergency release (ER) group O RBCs. This practice has been reported to be safe with a low rate of acute hemolytic ...transfusion reactions (AHRs).
Methods
Records of patients who received ER RBCs over a 30-month period were examined at our hospitals. During this period, satellite refrigerators were on site in the emergency department (ED), which were electronically connected to the blood bank (electronically connected satellite refrigerator ECSR). Nurses accessing the refrigerator were required to give patient identification information, when known, prior to removal of the ER RBCs, allowing technologists the opportunity to check for previous serologic records and communicate directly with the ED if a serologic incompatibility was potentially present.
Results
In total, 935 patients were transfused with 1,847 units of ER RBCs. Thirty of these patients had a current (22/30) or historic (8/30) antibody. In 15 cases, incompatible RBCs were interdicted. In six cases, the transfusion was considered urgent, and an AHR occurred in four of these six (overall 0.4%), including one fatal AHR due to anti-KEL1.
Conclusions
Use of KEL1-negative RBCs and ECSR merits consideration as approaches to mitigate the occurrence of ER RBC-associated AHRs.
Pediatric Stroke: A Review Tsze, Daniel S.; Valente, Jonathan H.
Emergency Medicine International,
01/2011, Volume:
2011
Journal Article
Peer reviewed
Open access
Stroke is relatively rare in children, but can lead to significant morbidity and mortality. Understanding that children with strokes present differently than adults and often present with unique risk ...factors will optimize outcomes in children. Despite an increased incidence of pediatric stroke, there is often a delay in diagnosis, and cases may still remain under- or misdiagnosed. Clinical presentation will vary based on the child's age, and children will have risk factors for stroke that are less common than in adults. Management strategies in children are extrapolated primarily from adult studies, but with different considerations regarding short-term anticoagulation and guarded recommendations regarding thrombolytics. Although most recommendations for management are extrapolated from adult populations, they still remain useful, in conjunction with pediatric-specific considerations.
This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the ...Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.
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