Delta troponin does not distinguish acute coronary syndrome in emergency department patients with renal impairment and an initial positive troponin.

Background: In emergency department (ED) patients with renal impairment, troponin concentrations can be positive without myocardial ischemia. When there is clinical concern for acute coronary syndrome (ACS), guidelines recommend obtaining a delta troponin measurement to identify acute myocardial injury. However, evidence supporting the use of delta troponin to rule in or out ACS in patients with renal impairment and initial elevated troponin levels is limited. Methods: This retrospective, observational study assessed the diagnostic value of a 20% delta troponin cutoff in the prediction of ACS events in ED patients (estimated glomerular filtration rate [eGFR] <60 mL/min/1.72 m2) with renal impairment, clinical concern for ACS, and an initial positive troponin concentration using either conventional troponin (cTnT) or high-sensitivity troponin (hsTnT). Clinical concern for ACS was based on initial ED physician-reported diagnoses. Patients with an initial diagnosis of ST-elevation myocardial infarction were not included. A positive initial troponin was identified at a threshold of ≥0.06 ng/mL for cTnT and ≥52 ng/L for hsTnT, and delta troponin measurements were obtained within 24 h of the initial troponin. The primary composite outcome, termed ACS event, included (1) cardiac-related mortality, (2) coronary revascularization (or its recommendation), or a (3) clinically diagnosed type-1 myocardial infarction within 6 weeks of the ED presentation. Sensitivities, specificities, negative predictive values, positive predictive values, and negative and positive likelihood ratios were calculated for these 6-week ACS events. Results: A total of 608 ED patients with renal impairment, an initial positive troponin, and clinical concern for ACS were included in the study. Of these patients, 234 had an initial positive cTnT (median eGFR 18 mL/min/1.72 m2) and 374 had an initial positive hsTnT (median eGFR 25 mL/min/1.72 m2). The overall ACS event rate was 38% in the cTnT group and 33% in the hsTnT group. In those with a negative delta, the 6-week ACS event rate was 32% when using cTnT, compared to 24% using hsTnT. Conversely, a positive delta was associated with an ACS event rate of 47% when cTnT was utilized versus 61% when hsTnT was utilized. Conclusion: In this study, approximately one-third of ED patients with renal impairment who had an initial positive troponin and clinical concern for ACS developed ACS events at 6 weeks. A delta troponin did not appear to provide clinically meaningful assistance in the prediction or exclusion of 6-week ACS events in this cohort.

COVID-lateral Damage: Impact of the Post-COVID-19 Era on Procedural Training in Emergency Medicine Residency.

Introduction: Hospitalizations during the coronavirus 2019 (COVID-19) pandemic peaked in New York in March-April 2020. In the months following, emergency department (ED) volumes declined. Our objective in this study was to examine the effect of this decline on the procedural experience of emergency medicine (EM) residents compared to the pre-pandemic period. Methods: We conducted this multicenter, retrospective cohort study of patients seen and key procedures performed by EM residents at hospitals spanning three Accreditation Committee for Graduate Medical Education-approved EM residencies in New York City and Nassau County, NY. We obtained numbers of procedures performed during May-July 2020 and compared them to the same time period for 2019 and 2018. We a priori classified critical care procedures-cardioversion, central lines, chest tubes, procedural sedation, and endotracheal intubation. We also studied "fast-track" procedures-fracture/joint reduction, incision and drainage (I&D), laceration repairs, and splints. Results: Total number of critical care procedures in the months following the COVID-19 peak decreased from 694 to 606 (-12.7%, 95% confidence interval [CI] 10.3-15.4%), compared to an increase from 642 to 694 (+8.1%, 95% CI 6.1-10.5%) the previous year (difference -9.3%). Total number of fast-track procedures decreased from 5,253 to 3,369 (-35.9%, 95% CI 34.6-37.2%), compared to a decrease from 5,333 to 5,253 (-1.5%, 95% CI 1.2-1.9%) the year before (difference -36.3%). Specific critical care procedures performed in 2020 compared to the mean of 2019 and 2018 as follows: cardioversion -33.3%; central lines +19.0%; chest tubes -27.9%; procedural sedation -30.8%; endotracheal intubation -13.8%. Specific fast-track procedures: reductions +33.3%; I&D -48.6%; laceration repair -17.3%; and splint application -49.8%. Conclusion: Emergency medicine residents' critical and fast-track procedural experience at five hospitals was reduced during the months following the COVID-19 peak in comparison to a similar period in the two years prior. Training programs may consider increasing simulation-lab and cadaver-lab experiences, as well as ED and critical care rotations for their residents to offset this trend.

Ultrasound Measurement of the Intervertebral Space in the Lateral Recumbent Versus Sitting Positions.

BACKGROUND: Diagnostic lumbar puncture (LP) is an invasive procedure routinely performed within the emergency department (ED). LP is traditionally performed with the patient in either the lateral recumbent or sitting position. We investigated if the intervertebral space is larger in one of these positions. If one position is larger than the other, this would imply that one position offers a higher chance of a successful lumbar puncture than the other position. OBJECTIVE: We sought to determine if there is a significant size difference of the L4/L5 intervertebral space in the lateral recumbent compared with the sitting position. METHODS: Point-of-care ultrasound (POCUS) was performed to measure the size of each volunteer's L4/L5 intervertebral space in both the seated and lateral recumbent positions. All volunteers >18 years of age were eligible for the study. Thirty volunteers had measurements taken. Three measurements were taken by each investigator in both positions for each volunteer. RESULTS: The median L4/L5 intervertebral space distance was 1.7511 cm in the lateral recumbent position and 1.9511 cm in the seated position with a Wilcoxon signed rank p value <.0001. The interspinous space in the seated position was found to be significantly larger than in the lateral recumbent position. CONCLUSION: The size of the interspinous space in the seated position on ultrasound was found to be larger than the lateral recumbent position, suggesting that LP may be more successful in the seated position.

Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium.

INTRODUCTION: Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development. METHODS: This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway. RESULTS: A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83). CONCLUSION: Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.

The Relationship Between Grit, Burnout, and Well-being in Emergency Medicine Residents.

BACKGROUND: Burnout has become endemic in medicine, across all specialties and levels of training. Grit, defined as "perseverance and passion for long-term goals," attempts to quantify the ability to maintain sustained effort throughout an extended length of time. Our objective is to assess burnout and well-being and examine their relationship with the character trait, grit, in emergency medicine residents. METHODS: In Fall 2016, we conducted a multicenter cross-sectional survey at five large, urban, academically affiliated emergency departments. Residents were invited to anonymously provide responses to three validated survey instruments; the Short Grit Scale, the Maslach Burnout Inventory, and the World Health Organization-5 Well-Being Index. RESULTS: A total of 222 residents completed the survey (response rate = 86%). A total of 173 residents (77.9%) met criteria for burnout and 107 residents (48.2%) met criteria for low well-being. Residents meeting criteria for burnout and low well-being had significantly lower mean grit scores than those that did not meet criteria. Residents with high grit scores had lower odds of experiencing burnout and low well-being (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.46-0.85; and [OR] = 0.33, 95% CI = 0.16-0.72, respectively). Residents with low grit scores were more likely to experience burnout and more likely to have low well-being (OR = 6.17, 95% CI = 1.43-26.64; and OR = 2.76, 95% CI = 1.31-5.79, respectively). CONCLUSION: A significant relationship exists between grit, burnout, and well-being. Residents with high grit appear to be less likely to experience burnout and low well-being while those with low grit are more likely to experience burnout and low well-being.

Geriatric Resuscitation.

The geriatric population makes up a large portion of the emergency patient population. Geriatric patients have less reserve and more comorbid diseases. They are frequently on multiple medications and are more likely to require aggressive treatment during acute illness. Although it may not be obvious, it is important to recognize the signs of shock as early as possible. Special care and monitoring should be used when resuscitating the elderly. The use of bedside ultrasound and monitoring for coagulopathies are discussed. Clinicians should be constantly vigilant and reassess throughout diagnosis and treatment. Ethical considerations in this population need to be considered on an individual basis.

Prehospital trauma arrival notification associated with more image studies in patients with minor head trauma discharged from ED.

OBJECTIVES: The objective of this study was to determine whether prehospital trauma arrival notification was associated with more head computed tomography (CT) scans and image studies performed in patients with minor head trauma and discharged from emergency department (ED). METHODS: A retrospective cross-sectional study based on hospital electronic medical record was performed. Patients with head trauma indicated by their diagnostic codes or chief complaints, presenting to and discharged from ED in a level I trauma center between January 1, 2010, and June 30, 2014, and triage Glasgow Coma Scale (GCS) score 14 or greater were selected from electronic medical record. Triage prehospital trauma arrival notification, number and types of image studies performed, and basic demographics were extracted. χ(2) Analysis (or Fisher test) was applied to compare the proportions of patients who received image studies between prehospital trauma arrival notification and non-notification groups. RESULTS: There were 3603 patients with head trauma, triage GCS score 14 or greater, and discharged from ED. Mean age was 43.8 years. Forty-six percent was female. Thirty-two point nine percent was Hispanic, and 28.6% was black. Numbers (proportions) of patients who received prehospital trauma arrival notification, head CT scan, or any image study (x-ray, CT, magnetic resonance imaging, or sonogram) were 287 (8.0%), 1621 (45.0%), and 2267 (63.0%), respectively. Compared with patients without prehospital trauma arrival notifications, patients with prehospital trauma arrival notifications were significantly more likely to receive a head CT scan as well as an image study. CONCLUSIONS: Prehospital trauma arrival notification was associated with significantly more head CT scans and more image studies in patients with minor head trauma and discharged from ED.