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Care of the critically ill begins in the emergency medicine setting. Eur J Emerg Med 2024; 31:165-168. [PMID: 38635471 DOI: 10.1097/mej.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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van Veelen NM, Buenter L, Kremo V, Peek J, Leiser A, Kestenholz P, Babst R, Paulus Beeres FJ, Minervini F. Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis. Front Surg 2023; 10:1120399. [PMID: 36755767 PMCID: PMC9899886 DOI: 10.3389/fsurg.2023.1120399] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
Background Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR. Methods Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea. Results Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea. Conclusion To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lea Buenter
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Valérie Kremo
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jesse Peek
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Correspondence: Fabrizio Minervini
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Kempster K, Howell S, Bernard S, Smith K, Cameron P, Finn J, Stub D, Morley P, Bray J. Out-of-hospital cardiac arrest outcomes in emergency departments. Resuscitation 2021; 166:21-30. [PMID: 34271123 DOI: 10.1016/j.resuscitation.2021.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals. METHODS Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC). RESULTS Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89-6.21). CONCLUSION Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality.
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Affiliation(s)
- Kalin Kempster
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; University of Melbourne, Australia
| | - Stuart Howell
- Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Alfred Hospital, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Department of Paramedicine, Monash University, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Alfred Hospital, Australia
| | - Judith Finn
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Ambulance Victoria, Australia; Alfred Hospital, Australia; Western Hospital, Australia
| | - Peter Morley
- University of Melbourne, Australia; Royal Melbourne Hospital, Australia
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia; Prehospital, Resuscitation & Emergency Care Research Unit, Curtin University, Australia.
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Kumle B, Merz S, Mittmann A, Pin M, Brokmann JC, Gröning I, Biermann H, Michael M, Böhm L, Wolters S, Bernhard M. Nichttraumatologisches Schockraummanagement. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-0613-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Roedl K, Wallmüller C, Drolz A, Horvatits T, Rutter K, Spiel A, Ortbauer J, Stratil P, Hubner P, Weiser C, Motaabbed JK, Jarczak D, Herkner H, Sterz F, Fuhrmann V. Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis. Ann Intensive Care 2017; 7:103. [PMID: 28986855 PMCID: PMC5630568 DOI: 10.1186/s13613-017-0322-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/19/2017] [Indexed: 12/16/2022] Open
Abstract
Background Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis. Methods Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient’s characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis. Results Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33–7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04–0.36). None of the patients with Child–Turcotte–Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days. Conclusion Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0322-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Thomas Horvatits
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Karoline Rutter
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Alexander Spiel
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Ortbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Peter Stratil
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jasmin Katrin Motaabbed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria.
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Sulzgruber P, Sterz F, Schober A, Uray T, Van Tulder R, Hubner P, Wallmüller C, El-Tattan D, Graf N, Ruzicka G, Schriefl C, Zajicek A, Buchinger A, Koller L, Laggner AN, Spiel A. Editor’s Choice-Progress in the chain of survival and its impact on outcomes of patients admitted to a specialized high-volume cardiac arrest center during the past two decades. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:3-12. [DOI: 10.1177/2048872615620904] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Andreas Schober
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Thomas Uray
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Diana El-Tattan
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Nikolaus Graf
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Gerhard Ruzicka
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | | | | | - Lorenz Koller
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Anton N Laggner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Alexander Spiel
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Schober A, Sterz F, Laggner AN, Poppe M, Sulzgruber P, Lobmeyr E, Datler P, Keferböck M, Zeiner S, Nuernberger A, Eder B, Hinterholzer G, Mydza D, Enzelsberger B, Herbich K, Schuster R, Koeller E, Publig T, Smetana P, Scheibenpflug C, Christ G, Meyer B, Uray T. Admission of out-of-hospital cardiac arrest victims to a high volume cardiac arrest center is linked to improved outcome. Resuscitation 2016; 106:42-8. [DOI: 10.1016/j.resuscitation.2016.06.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/31/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
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Bray JE, Bernard S, Cantwell K, Stephenson M, Smith K. The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology. Resuscitation 2013; 85:509-15. [PMID: 24333351 DOI: 10.1016/j.resuscitation.2013.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/21/2013] [Accepted: 12/02/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND The optimal blood pressure target following successful resuscitation from out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to explore the association between level of systolic blood pressure (SBP) on arrival at hospital and survival to hospital discharge. METHODS We analysed eligible OHCAs occurring between January 2003 and December 2011 from the Victorian Ambulance Cardiac Arrest Register (VACAR). Inclusion criteria were: adults (≥18 years), presumed cardiac aetiology, not paramedic witnessed, and ROSC at hospital arrival. Multivariate logistic regression models were performed by initial rhythm (shockable/non-shockable) to examine the relationship between SBP at hospital arrival in 10 mmHg increments and survival to hospital discharge. Models were adjusted for known predictors of survival, including duration of arrest. RESULTS Of 3620 eligible cases, 14% were hypotensive (SBP<90 mmHg) on hospital arrival (10% shockable and 19% non-shockable). For patients in shockable rhythms, discharge survival was maximal at 120-129 mmHg (54%), and in the adjusted model (≥120 mmHg as reference) SBP decrements below 90 mmHg were associated with lower survival: 80-89 mmHg AOR=0.49 (95% CI: 0.24-0.95); <80 mmHg AOR=0.24 (95% CI: 0.10-0.61); unrecordable AOR=0.10 (95% CI: 0.04-0.30). In patients found in non-shockable rhythms, SBP was not significant associated with discharge survival (AOR=1.01, 95% CI: 0.89-1.15). CONCLUSIONS In an EMS system using intravenous adrenaline and fluids to maintain post-resuscitation SBP at 120 mmHg, hypotension on hospital arrival was relatively uncommon. However, in presumed cardiac OHCA patients with an initial shockable rhythm, SBPs below 90 mmHg was associated with significant lower odds of survival to hospital discharge. This level of hypotension may indicate patients who require more aggressive post-resuscitation blood pressure management.
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Affiliation(s)
- Janet E Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Level 5, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia.
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Level 5, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Ambulance Victoria, 375 Manningham Road, Doncaster, Victoria 3108, Australia; Alfred Hospital, Commercial Road, Melbourne, Victoria 3004, Australia
| | - Kate Cantwell
- Department of Epidemiology and Preventive Medicine, Monash University, Level 5, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Ambulance Victoria, 375 Manningham Road, Doncaster, Victoria 3108, Australia; Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Michael Stephenson
- Department of Epidemiology and Preventive Medicine, Monash University, Level 5, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Ambulance Victoria, 375 Manningham Road, Doncaster, Victoria 3108, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Level 5, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; Ambulance Victoria, 375 Manningham Road, Doncaster, Victoria 3108, Australia; Department of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Weingart SD, Sherwin RL, Emlet LL, Tawil I, Mayglothling J, Rittenberger JC. ED intensivists and ED intensive care units. Am J Emerg Med 2013; 31:617-20. [PMID: 23380127 DOI: 10.1016/j.ajem.2012.10.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/12/2012] [Accepted: 10/16/2012] [Indexed: 11/15/2022] Open
Affiliation(s)
- Scott D Weingart
- Division of Emergency Critical Care, Mount Sinai School of Medicine, New York,NY 11373, USA.
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