Journal Club

January Journal Club

Thursday January 26, 2012
6:30 PM
5510 Cramblet Hall Conference Room
 
Journal Club Vignette
 
You are working in the ED at a community hospital when a 57 year old female patient arrives with a chief complaint of numbness. She gives a history of right arm and leg numbness and tingling that occurred just prior to arrival; she feels her arm is almost back to normal at this time. On exam, her vitals are: HR 88, BP 144/86, RR 16, Temp 98.8 and 97% on room air. Her CNS exam demonstrates 5/5 strength of all four extremities and her sensory exam is intact with no focal abnormalities. An NIH stroke scale is performed and is zero. A stat head CT is ordered which is read as normal. You order additional diagnostics including ECG, CBC, BMP, PT/INR, UA and place her in a monitored bed with frequent neuro checks. Obtaining additional history, she tells you she has high blood pressure treated with medication, and type 2 diabetes treated only with diet. She says the symptoms started and resolved over a period of about 45 minutes; they have completely resolved at present. Her ECG and lab work are unremarkable. You are working in a hospital without onsite neurology, and no observation unit. The patient, now improved, would like to go home and follow up with her doctor. Can she be safely discharged or should be persuaded to stay for a hospital admission? You review the literature to find out the best disposition for your patient and whether discharge after TIA can be recommended.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with TIA
Intervention:Discharge with Close Outpatient Follow up
Comparison:Hospitalization
Outcome:Mortality, CVA
 
Search Strategy: Pubmed; Keywords: TIA AND ABCD Score Limits: English, Adults, humans Results: 48 articles. 3 selected for review:
 
Chandratheva A, Geraghty OC, Luengo-Fernandez R, Rothwell PM: ABCD2 score predicts severity rather than risk of early recurrent events after transient ischemic attack. Stroke 2010 41:5 p851-6.
 
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Holzer K, Feurer R, Sadikovic S, Esposito L, Bockelbrink A, Sander D, Hemmer B, Poppert H: Prognostic value of the ABCD2 score beyond short-term follow-up after transient ischemic attack (TIA)--a cohort study. BMC Neurol 2010 10: p50.
 
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Tsivgoulis G, Stamboulis E, Sharma VK, Heliopoulos I, Voumvourakis K, Teoh HL, Patousi A, Andrikopoulou A, Lim EL, Stilou L, Sim TB, Chan BP, Stefanis L, Vadikolias K, Piperidou C: Multicenter external validation of the ABCD2 score in triaging TIA patients. Neurology 2010 74:17 p1351-7.
 
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Extra Articles:
 
National Stroke Association Transient Ischemic Attack (TIA): Prognosis and Key Management Considerations
 
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February Journal Club

Thursday February 23, 2012
6:30 PM
Room 400 A & B Prior Health Science Library
 
Journal Club Vignette
 
It's the overnight shift at your small community hospital. You get a call from EMS that they are bringing a 55 year old male who sustained a witnessed V-fib arrest. He received ACLS and defibrillation and now has a pulse. In anticipation of the patient's arrival, you ask your nurses and techs to set up for the initiation of therapeutic hypothermia. They state that no such protocol exists and that they have not utilized therapeutic hypothermia in their department in the past. Intrigued, you wonder how they cannot be familiar with such a protocol as strong evidence touting its benefit has been around for several years. You take it upon yourself to introduce a hypothermia protocol at your institution so that your team is better prepared in the future. In order to be prepared for potential obstacles to its implementation, you perform a literature search to identify some of the impediments you may face when attempting to introduce such a protocol.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Physicians, hospitals
Intervention:Specific approach to implementation of new therapy
Comparison:Standard implementation techniques
Outcome:Success of implementation, change in behavior
 
Search Strategy: Pubmed; Keywords: implementation science AND therapeutic hypothermia Limits: English, Adults, humans Results: 10 articles. 3 selected for review:
 
Walters JH, Morley PT, Nolan JP: The role of hypothermia in post-cardiac arrest patients with return of spontaneous ciruculation: a systematic review. Resuscitation May 2011
 
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Toma A, Bensimon CM, Dainty KN, Rubenfeld GD, Morrison LJ, Brooks SC: Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: a qualitative study of emergency department and critical care workers. Critical Care Medicine February 2010
 
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Bigham BL, Dainty KN, Scales DC, Morrison LJ, Brooks SC: Predictors of adopting therapeutic hypothermia for post-cardiac arrest patients among Candaian emergency and critical care physicians. Resuscitation January 2010
 
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Extra Articles:
 
Brooks SC, Morrison LJ: Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: Seeking guidance from the knowledge translation literature. Resuscitation 2008 77:286-92.
 
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March Journal Club

Thursday March 29, 2012
6:30 PM
Room 400 A & B Prior Health Science Library
 
Journal Club Vignette
 
You are working a shift at a community ED when a 72-year-old female is brought for evaluation by her family. The patient's daughter states that she has been acting differently for the past week. She lives alone and you discover that her husband of 51 years just passed away 2 months ago. Her daughter states that she handled everything well but has been withdrawn and acting "different" during her daily visits over the last couple of weeks. The daughter is unsure if she is eating and taking her medications properly. The patient has numerous medical problems including type 2 DM, CAD, HTN, back pain, depression, COPD, afib. She takes numerous medications that you are unable to obtain. The patient refuses to talk to you during the encounter. Her vitals are HR 101, BP 168/96, RR 18, T 99 F, and 96% on RA. Given the patient history and physical you are unsure if the patient's symptoms are due to grieving process, delirium, dementia, or psychiatric cause. You decide to review the literature to identify an effective and efficient screening tool to detect mental status impairment in geriatric ED patients.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Geriatric patients with potential cognitive impairment
Intervention:Formal screening tools to detect cognitive impairment
Comparison:Standard screening evaluation techniques
Outcome:Sensitivity, specificity, NPV, PPV of identifying cognitive impairment in ED
 
Search Strategy: Pubmed; Keywords: cognitive impairment AND emergency medicine Results: 77 articles. 3 selected for review:
 
Hustey FM, Meldon SW, Smith MD, Lex CK: The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003 41:5 p678-84.
 
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Carpenter CR, Bassett ER, Fischer GM, Shirshekan J, Galvin JE, Morris JC: Four sensitive screening tools to detect cognitive dysfunction in geriatric emergency department patients: brief Alzheimer's Screen, Short Blessed Test, Ottawa 3DY, and the caregiver-completed AD8. Acad Emerg Med 2011 18:4 p374-84.
 
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Shah MN, Karuza J, Rueckmann E, Swanson P, Conwell Y, Katz P: Reliability and validity of prehospital case finding for depression and cognitive impairment. J Am Geriatr Soc 2009 57:4 p697-702.
 
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April Journal Club

Thursday April 26, 2012
6:30 PM
Room 400 A/B Prior HSL
 
Journal Club Vignette
 
You are the medical director for the Emergency Department at your institution. You learn that one of your fellow ED colleagues is abusing alcohol. You decide to approach your colleague, expressing your concern with his/her behavior and how it is affecting his/her medical decision making. Your colleague explains that he/she is dissatisfied with the work environment, poor team communication, and resulting family conflict. After speaking with your colleague, you also learn that several other physicians in your group have similar feelings of job dissatisfaction. You decide to learn more about job satisfaction/dissatisfaction pertaining to Emergency Medicine physicians and what factors lead them to dissatisfaction and substance use.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Emergency medicine physicians
Intervention:methods of improving job satisfaction
Comparison:standard work environment
Outcome:physician burnout, stress, substance abuse
 
Search Strategy: Pubmed; Keywords: emergency medicine AND job satisfaction Results: 172 articles. 3 selected for review:
 
McBeth BD, Ankel FK, Ling LJ, Asplin BR, Mason EJ, Flottemesch TJ, McNamara RM: Substance use in emergency medicine training programs. Acad Emerg Med 2008 15:1 p45-53.
 
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Estryn-Behar M, Doppia MA, Guetarni K, Fry C, Machet G, Pelloux P, Aune I, Muster D, Lassauniere JM, Prudhomme C: Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study. Emerg Med J 2011 28:5 p397-410.
 
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Cydulka RK, Korte R: Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008 51:6 p714-722.e1.
 
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Extra Articles:
 
Shah M: Chronicles of an emergency medicine intern. Acad Emerg Med 2007 14:5 p475-6.
 
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Houry D, Shockley LW, Markovchick V: Wellness issues and the emergency medicine resident. Ann Emerg Med 2000 35:4 p394-7.
 
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May Journal Club

Thursday May 31, 2012
6:30 PM
400 A B Prior Health Science Library
 
Journal Club Vignette
 
You are in charge of your city's EMS system and are in charge of protocol development. Some of your medics have started complaining to you about how difficult it is to obtain IV access in the heroin overdose patients they take care of and are wondering if there is an alternative to IV narcan in the non-intubated patient. Additionally, many of the OD victims are upset and agitated after given narcan and many do not want to be transported to the hospital. The medics want to know if it is safe to allow them to sign out AMA after giving them narcan if awake, alert, and oriented.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:EMS patients with heroin OD
Intervention:IM/IN Narcan
Comparison:IV Narcan
Outcome:Morbidity, Mortality
 
Search Strategy: Pubmed; Keywords: EMS and Narcan Score Results: 25 articles. 3 selected for review:
 
Vilke GM, Sloane C, Smith AM, Chan TC: Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med 2003 10:8 p893-6.
 
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Robertson TM, Hendey GW, Stroh G, Shalit M: Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care 2009 13:4 p512-5.
 
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Kerr D, Kelly AM, Dietze P, Jolley D, Barge: Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction 2009 104:12 p2067-74.
 
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Extra Articles:
 
Sporer KA, Kral AH: Prescription naloxone: a novel approach to heroin overdose prevention. Ann Emerg Med 2007 49:2 p172-7.
 
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Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA: Commonly prescribed medications and potential false-positive urine drug screens. Am J Health Syst Pharm 2010 67:16 p1344-50.
 
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July Journal Club

Wednesday July 25, 2012
11:00 AM
M-100 Starling Loving Hall
 
Journal Club Vignette
 
A 40 year old female presents with a sudden onset of severe headache that developed approximately 3 hours ago. The patient states she was doing some gardening in the yard and lifting mulch when the headache developed. It is diffuse with associated nausea and feeling lightheaded with associated dizziness. She does state it is one of the worst headaches she has had in the past. She has a history of migraines although this is slightly different. On examination, her blood pressure is 160/80, HR 102, RR 16, T 98.5. Her exam reveals an uncomfortable female lying in the dark with obvious photophobia. Her CNS exam is otherwise non-focal. She has a head CT done within one hour of arrival with a newer generation CT that is interpreted as negative per the neuroradiologist. Your attending recommends a lumbar puncture to rule out a SAH however, the patient is improved with a migraine cocktail and does not think it is necessary. You are unsure of how accurate a CT would be in this case.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED Patients with suspected SAH
Intervention:Non-contrast Head CT
Comparison:Non-contrast Head CT + LP
Outcome:Sensitivity, Specificity, NPV, PPV
 
Search Strategy: Subarachnoid hemorrhage and CT and sensitivity. English, 317 articles, 3 selected (with one extra)
 
Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ: Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med 2008 51:6 p697-703.
 
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Gee C, Dawson M, Bledsoe J, Ledyard H, Phanthavady T, Youngquist S, McGuire T, Madsen T: Sensitivity of Newer-generation Computed Tomography Scanners for Subarachnoid Hemorrhage: A Bayesian Analysis. J Emerg Med 2012 : epub ahead of print.
 
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Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Emond M, Symington C, Sutherland J, Worster A, Hohl C, Lee JS, Eisenhauer MA, Mortensen M, Mackey D, Pauls M, Lesiuk H, Wells GA: Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011 343: pd4277.
 
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Extra Articles:
 
McCormack RF, Hutson A: Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan?. Acad Emerg Med 2010 17:4 p444-51.
 
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August Journal Club

Wednesday August 29, 2012
11:00 AM
M-100 Starling Loving Hall
 
Journal Club Vignette
 
A 45 year old male with history of alcoholic cirrhosis presents with acute onset hematemesis for the past 3 hours. He reports a history of GI bleeding with esophageal varices on previous endoscopies. He is currently vomiting up bright red blood. Upon arrival, BP 100/50, HR 120, T 99.0, RR 22, SaO2 94%. Exam reveals no abdominal tenderness/guarding/rebound, +fluid wave with a known history of ascites. You start IVF bolus through 2 large bore IVs, send lab work, and start both nexium and octreotide drips. Your attending asks if you would like to start IV antibiotics and you're unsure if this is appropriate given that the patient is afebrile without clinical evidence of infection.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:ED patients with cirrhosis presenting with acute upper GI bleed
Intervention:Standard therapy with IV antibiotics
Comparison:Standard therapy
Outcome:Overall mortality, infection rate, rate of rebleeding
 
Search Strategy:
 
Jun CH, Park CH, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ, Kim YD: Antibiotic prophylaxis using third generation cephalosporins can reduce the risk of early rebleeding in the first acute gastroesophageal variceal hemorrhage: a prospective randomized study. J Korean Med Sci 2006 21:5 p883-90.
 
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Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T: Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999 29:6 p1655-61.
 
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Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M: Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther 2011 34:5 p509-18.
 
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Extra Articles:
 
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M: Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010 :9 pCD002907.
 
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Vivas S, Rodriguez M, Palacio MA, Linares A, Alonso JL, Rodrigo L: Presence of bacterial infection in bleeding cirrhotic patients is independently associated with early mortality and failure to control bleeding. Dig Dis Sci 2001 Dec 46(12):2752-7.
 
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September Journal Club

Wednesday September 26, 2012
11:00 AM
M-100 Starling Loving Hall
 
Journal Club Vignette
 
78 yowf with history of atrial fibrillation on warfarin presents with altered mental status after a mechanical fall where she struck her head on the wall. Her vitals are stable but she confused to time and place. She is able to move all extremities. You put her in a c-collar and order a head CT and labs. She has an INR of 4.2 and has a 1cm right sided subdural hematoma with effacement of her lateral ventricle but no shift. As you consult neurosurgery, you begin to order fresh frozen plasma to reverse her elevated INR. Your attending mentions you could use prothrombin complex concentrates instead of FFP because it works faster. That night you decide to investigate PCC and the evidence behind it.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Patients with hemorrhage and elevated INR
Intervention:Prothrombin Complex Concentrate (PCC)
Comparison:Fresh frozen plasma (FFP)
Outcome:Improved survival or neurologic function
 
Search Strategy: Pubmed prothrombin complex and bleeding or warfarin
 
Imberti D, Barillari G, Biasioli C, Bianchi M, Contino L, Duce R, D'Incà M, Gnani MC, Mari E, Ageno W: Emergency reversal of anticoagulation with a three-factor prothrombin complex concentrate in patients with intracranial haemorrhage. Blood Transfus 2011 9:2 p148-55.
 
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Demeyere R, Gillardin S, Arnout J, Strengers PF: Comparison of fresh frozen plasma and prothrombin complex concentrate for the reversal of oral anticoagulants in patients undergoing cardiopulmonary bypass surgery: a randomized study. Vox Sang 2010 99:3 p251-60.
 
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Huttner HB, Schellinger PD, Hartmann M, Köhrmann M, Juettler E, Wikner J, Mueller S, Meyding-Lamade U, Strobl R, Mansmann U, Schwab S, Steiner T: Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke 2006 37:6 p1465-70.
 
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October Journal Club

Wednesday October 31, 2012
11:00 AM
M-100 Starling Loving Hall
 
Journal Club Vignette
 
You graduate from residency and head back to your hometown for your new job in a local community hospital. During your first month you receive a call by EMS stating they are bringing in a patient who had a vfib arrest and has had return of circulation. After the patient arrives intubated and unconscious, you notice the paramedic did not initiate prehospital cooling as you would have expected to happen at Ohio State. You ask the paramedic and he informs you that is not a part of their protocols. You contact their medical director, hoping to change their protocols. The EMS medical director asks you for the evidence supporting this practice.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Vfib/vtach cardiac arrest patients with ROSC
Intervention:Prehospital initiation of therapeutic hypothermia
Comparison:Standard therapy (ED initiation of therapeutic hypothermia)
Outcome:Survival to hospital discharge, neurologic outcome
 
Search Strategy: Pubmed, cochrane: therapeutic hypothermia AND cardiac arrest AND prehospital OR out-of-hospital
 
Hinchey PR, Myers JB, Lewis R, De Maio VJ, Reyer E, Licatese D, Zalkin J, Snyder G: Improved out-of-hospital cardiac arrest survival after the sequential implementation of 2005 AHA guidelines for compressions, ventilations, and induced hypothermia: the Wake County experience. Ann Emerg Med 2010 56:4 p348-57.
 
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Bernard SA, Smith K, Cameron P, Masci K, Taylor DM, Cooper DJ, Kelly AM, Silvester W: Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010 122:7 p737-42.
 
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Cabanas JG, Brice JH, De Maio VJ, Myers B, Hinchey PR: Field-induced therapeutic hypothermia for neuroprotection after out-of hospital cardiac arrest: a systematic review of the literature. J Emerg Med 2011 40:4 p400-9.
 
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November Journal Club

Wednesday November 28, 2012
11:00 AM
M-100 Starling Loving Hall
 
Journal Club Vignette
 
You are working in an emergency department when a forty three year old patient with moderate developmental delay presents for evaluation of possible carbon monoxide exposure. The patient was sent in after the CO detector in his group home went off. Other than agitation, which could be secondary to the new environment in the emergency department, the patient’s physical exam is unremarkable. The patient is already upset and you are concerned that obtaining a blood specimen for co-oximetry might prove difficult. You wonder whether you can use a point-of-care testing to exclude significant carbon monoxide exposure and decide to turn to the literature for guidance.
 
To Investigate this, the following approach is explored:
 
PICO Question
 
Population:Adult patients presenting with possible carbon monoxide poisoning (eg. not CO screening of large populations)
Intervention:Carboxyhemoglobin levels obtained from noninvasive multiwave pulse-oximetry
Comparison:Carboxyhemoglobin levels obtained from blood gas analysis
Outcome:Ability to detect significant CO poisoning
 
Search Strategy: Pubmed -
 
Zaouter C, Zavorsky GS: The measurement of carboxyhemoglobin and methemoglobin using a non-invasive pulse CO-oximeter. Respir Physiol Neurobiol 2012 182:2-3 p88-92.
 
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Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P: Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement. Ann Emerg Med 2010 56:4 p382-8.
 
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Roth D, Herkner H, Schreiber W, Hubmann N, Gamper G, Laggner AN, Havel C: Accuracy of noninvasive multiwave pulse oximetry compared with carboxyhemoglobin from blood gas analysis in unselected emergency department patients. Ann Emerg Med 2011 58:1 p74-9.
 
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