Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and lifethreatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.

Objectives: The authors sought to describe the demographic and clinical characteristics of interhospital transfers from U.S. emergency departments (EDs) along with the primary reasons for transfers.Methods: This was a retrospective, cross-sectional analysis of the 1997 through 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visit-level characteristics were compared for patients who were transferred, admitted, or discharged. Additionally, data on primary reason for transfer for available years (2005 through 2008) were reviewed. Weighted analyses produced nationally representative estimates.Results: During this time period, 1.8% (95% confidence interval [CI] = 1.7% to 2.0%) of ED patients were transferred to other hospitals. Compared to visits resulting in admission, those resulting in transfer were more likely to involve patients who were <18 years old (18% vs. 7.9%), male (53% vs. 46%), with Medicaid (22% vs. 16%) or self-payment (15% vs. 8.2%) as a primary expected source of payment, having a visit related to injury (40% vs. 19%), and from a nonurban ED (29% vs. 15%). Among transferred patients, 28% (95% CI = 27% to 30%) received four to six diagnostic tests, and 31% (95% CI = 29% to 34%) received more than six diagnostic tests prior to transfer; 52% (95% CI = 50% to 54%) had diagnostic imaging, and 17% (95% CI = 16% to 19%) had cross-sectional imaging. Of the patients transferred from 2005 through 2008, 47% (95% CI = 43% to 53%) were transferred for a higher level of care, and 29% (95% CI = 26% to 35%) were transferred for psychiatric care. Conclusions:Transfer of ED patients was relatively rare, but was more common among specific, potentially high-risk populations. Diagnostic testing, including advanced imaging, was common prior to transfer. A majority of transfers were for reasons indicating limited resources or expertise at the referring facility.ACADEMIC EMERGENCY MEDICINE 2013; 20:888-893

Avalanche fatalities have increased. This is most likely related to an overall rise in backcountry utilization. Fatalities have increased among snowmobilers and snowboarders. Despite a rise in backcountry utilization, avalanche fatalities in Colorado are decreasing. A strategy of focused training and education aimed toward at-risk groups could result in lower avalanche fatalities.

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