High risk and low prevalence diseases: Myocarditis.

INTRODUCTION: Myocarditis is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of myocarditis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Myocarditis is an inflammatory syndrome of myocardium, most often resulting from a viral infection, that can cause life-threatening cardiovascular collapse. It has a highly variable presentation and no widely available specific diagnostic test, making it a challenging diagnosis. Emergency clinicians should obtain an electrocardiogram and perform bedside ultrasound to assess cardiac function. Treatment in the ED is largely supportive, focusing on resuscitation, cardiovascular support, cardiology specialist consultation, and appropriate disposition. CONCLUSIONS: An understanding of myocarditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

The critical care literature 2022.

The number of critically ill patients that present to emergency departments across the world has risen steadily for nearly two decades. Despite a decrease in initial emergency department (ED) volumes early in the COVID-19 pandemic, the proportion of critically ill patients is now higher than pre-pandemic levels [1]. The emergency physician (EP) is often the first physician to evaluate and resuscitate a critically ill patient. In addition, EPs are frequently tasked with providing critical care long beyond the initial resuscitation. Prolonged boarding of critically ill patients in the ED is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality [2-4]. Given the continued increase in critically ill patients along with the increases in boarding critically ill patients in the ED, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill patients continue to receive evidence-based care. This review summarizes important articles published in 2022 that pertain to the resuscitation and management of select critically ill ED patients. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, and sepsis.

Malaria: A focused review for the emergency medicine clinician.

INTRODUCTION: Malaria is a potentially fatal parasitic disease transmitted by the Anopheles mosquito. A resurgence in locally acquired infections has been reported in the U.S. OBJECTIVE: This narrative review provides a focused overview of malaria for the emergency clinician, including the epidemiology, presentation, diagnosis, and management of the disease. DISCUSSION: Malaria is caused by Plasmodium and is transmitted by the Anopheles mosquito. Disease severity can range from mild to severe. Malaria should be considered in any returning traveler from an endemic region, as well as those with unexplained cyclical, paroxysms of symptoms or unexplained fever. Patients most commonly present with fever and rigors but may also experience cough, myalgias, abdominal pain, fatigue, vomiting, and diarrhea. Hepatomegaly, splenomegaly, pallor, and jaundice are findings associated with malaria. Although less common, severe malaria is precipitated by microvascular obstruction with complications of anemia, acidosis, hypoglycemia, multiorgan failure, and cerebral malaria. Peripheral blood smears remain the gold standard for diagnosis, but rapid diagnostic tests are available. Treatment includes specialist consultation and antimalarial drugs tailored depending on chloroquine resistance, geographic region of travel, and patient comorbidities. Supportive care may be required, and patients with severe malaria will require resuscitation. Most patients will require admission for treatment and further monitoring. CONCLUSION: Emergency medicine clinicians should be aware of the presentation, diagnosis, evaluation, and management of malaria to ensure optimal outcomes.

Are People Generous When the Financial Stakes Are High?

How generous are people when making consequential financial decisions in the real world? We took advantage of a rare opportunity to examine generosity among a diverse sample of adults who received a gift of U.S. $10,000 from a pair of wealthy donors, with nearly no strings attached. Two-hundred participants were drawn from three low-income countries (Indonesia, Brazil, and Kenya) and four high-income countries (Australia, Canada, the United Kingdom, and the United States) as part of a preregistered study. On average, participants spent over $6,400 on purchases that benefited others, including nearly $1,700 on donations to charity, suggesting that humans exhibit remarkable generosity even when the stakes are high. To address whether generosity was driven by reputational concerns, we asked half the participants to share their spending decisions publicly on Twitter, whereas the other half were asked to keep their spending private. Generous spending was similar between the groups, in contrast to our preregistered hypothesis that enhancing reputational concerns would increase generosity.

Emergency medicine updates: Atrial fibrillation with rapid ventricular response.

INTRODUCTION: Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia. OBJECTIVE: This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician. DISCUSSION: Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions. CONCLUSION: An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.

Diagnosis and management of arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder of the myocardium that can lead to ventricular arrhythmia and sudden cardiac death. The condition has been identified as a significant cause of arrhythmic death among young people and athletes, therefore, early recognition of the disease by emergency clinicians is critical to prevent subsequent death. The diagnosis of ARVC can be very challenging and requires a systematic approach. This publication reviews the pathophysiology, classification, clinical presentations, and appropriate approach to diagnosis and management of ARVC.

Dysrhythmias associated with COVID-19: Review and management considerations.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is known to affect the cardiovascular system. Cardiac manifestations in COVID-19 can be due to direct damage to the myocardium and conduction system as well as by the disease's effect on the various organ systems. These manifestations include acute coronary syndrome, ST- segment elevations, cardiomyopathy, and dysrhythmias. Some of these dysrhythmias can be detrimental to the patient. Therefore, it is important for the emergency physician to be aware of the different arrhythmias associated with COVID-19 and how to manage them. This narrative review discusses the pathophysiology underlying the various arrhythmias associated with COVID-19 and their management considerations.

The critical care literature 2021.

An emergency physician (EP) is often the first provider to evaluate, resuscitate, and manage a critically ill patient. Over the past two decades, the annual hours of critical care delivered in emergency departments across the United States has dramatically increased. During the period from 2006 to 2014, the extent of critical care provided in the emergency department (ED) to critically ill patients increased approximately 80%. During the same time period, the number of intubated patients cared for in the ED increased by approximately 16%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. Prolonged ED boarding times for critically ill patients is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality. As a result, it is imperative for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine, so that the critically ill ED patient care receive current evidence-based care. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, cardiogenic shock, transfusions, and sepsis.

Mimics of Monkeypox: Considerations for the emergency medicine clinician.

INTRODUCTION: Mpox, formerly known as monkeypox, is a public health emergency most commonly presenting with a painful rash and several systemic findings. However, there are several conditions that may mimic its presentation. OBJECTIVE: This narrative review provides a focused overview of mpox mimics for emergency clinicians. DISCUSSION: Mpox is a global health emergency. The disease is primarily spread through contact, followed by the development of a centrifugally-spread rash that evolves from macules to papules to vesicles to pustules. This is often associated with lymphadenopathy and fever. As the rash is one of the most common presenting signs of the infection, patients mpox may present to the emergency department (ED) for further evaluation. There are a variety of mimics of mpox, including smallpox, varicella, primary and secondary syphilis, acute retroviral syndrome, and genital herpes simplex virus. CONCLUSION: Knowledge of mpox and its mimics is vital for emergency clinicians to differentiate these conditions and ensure appropriate diagnosis and management.

Ebola virus disease: A review for the emergency medicine clinician.

INTRODUCTION: Ebolavirus, the causative agent of Ebola virus disease (EVD) has been responsible for sporadic outbreaks mainly in sub-Saharan Africa since 1976. EVD is associated with high risk of transmission, especially to healthcare workers during patient care. OBJECTIVE: The purpose of this review is to provide a concise review of EVD presentation, diagnosis, and management for emergency clinicians. DISCUSSION: EVD is spread through direct contact, including blood, bodily fluids or contact with a contaminated object. Patients may present with non-specific symptoms such as fevers, myalgias, vomiting, or diarrhea that overlap with other viral illnesses, but rash, bruising, and bleeding may also occur. Laboratory analysis may reveal transaminitis, coagulopathy, and disseminated intravascular coagulation. The average clinical course is approximately 8-10 days with an average case fatality rate of 50%. The mainstay of treatment is supportive care, with two U.S. Food and Drug Administration-approved monoclonal antibody treatments (Ebanga and Inmazeb). Survivors of the disease may have a complicated recovery, marked by long-term symptoms. CONCLUSION: EVD is a potentially deadly condition that can present with a wide range of signs and symptoms. Emergency clinicians must be aware of the presentation, evaluation, and management to optimize the care of these patients.

Local anesthetic systemic toxicity: A narrative review for emergency clinicians.

INTRODUCTION: Emergency clinicians utilize local anesthetics for a variety of procedures in the emergency department (ED) setting. Local anesthetic systemic toxicity (LAST) is a potentially deadly complication. OBJECTIVE: This narrative review provides emergency clinicians with the most current evidence regarding the pathophysiology, evaluation, and management of patients with LAST. DISCUSSION: LAST is an uncommon but potentially life-threatening complication of local anesthetic use that may be encountered in the ED. Patients at extremes of age or with organ dysfunction are at higher risk. Inadvertent intra-arterial or intravenous injection, as well as repeated doses and higher doses of local anesthetics are associated with greater risk of developing LAST. Neurologic and cardiovascular manifestations can occur. Early recognition and intervention, including supportive care and intravenous lipid emulsion 20%, are the mainstays of treatment. Using ultrasound guidance, aspirating prior to injection, and utilizing the minimal local anesthetic dose needed are techniques that can reduce the risk of LAST. CONCLUSIONS: This focused review provides an update for the emergency clinician to manage patients with LAST.

Transcatheter aortic valve replacement complications: A narrative review for emergency clinicians.

INTRODUCTION: Aortic valve stenosis (AS) is present in up to 10% of individuals over age 80 years. Transcatheter aortic valve replacement (TAVR) has become the most common method to replace the aortic valve in patients with AS. TAVR-related complications may occur. OBJECTIVE: This narrative review evaluates the emergency department (ED) assessment and management of patients with TAVR complications. DISCUSSION: Post-TAVR complications can be conceptualized as occurring peri-procedurally and after the peri-procedural period. Peri-procedural complications include device landing zone rupture, coronary artery obstruction, acute myocardial infarction, cardiac tamponade, and valve embolization. Complications beyond the peri-procedural window include vascular access/bleeding, mechanical valve issues, electrical conduction complications, and end-organ damage. CONCLUSIONS: Emergency clinicians are more likely to encounter TAVR complications after the initial procedural hospitalization and must be prepared to diagnose and manage these complications.

Clinical update on COVID-19 for the emergency clinician: Airway and resuscitation.

INTRODUCTION: Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. OBJECTIVE: This narrative review provides emergency clinicians with a focused update of the resuscitation and airway management of COVID-19. DISCUSSION: Patients with COVID-19 and septic shock should be resuscitated with buffered/balanced crystalloids. If hypotension is present despite intravenous fluids, vasopressors including norepinephrine should be initiated. Stress dose steroids are recommended for patients with severe or refractory septic shock. Airway management is the mainstay of initial resuscitation in patients with COVID-19. Patients with COVID-19 and ARDS should be managed similarly to those ARDS patients without COVID-19. Clinicians should not delay intubation if indicated. In patients who are more clinically stable, physicians can consider a step-wise approach as patients' oxygenation needs escalate. High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) are recommended over elective intubation. Prone positioning, even in awake patients, has been shown to lower intubation rates and improve oxygenation. Strategies consistent with ARDSnet can be implemented in this patient population, with a goal tidal volume of 4-8 mL/kg of predicted body weight and targeted plateau pressures <30 cm H2O. Limited data support the use of neuromuscular blocking agents (NBMA), recruitment maneuvers, inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation (ECMO). CONCLUSION: This review presents a concise update of the resuscitation strategies and airway management techniques in patients with COVID-19 for emergency medicine clinicians.

Clinical update on COVID-19 for the emergency clinician: Cardiac arrest in the out-of-hospital and in-hospital settings.

INTRODUCTION: Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. Its impact on the health and welfare of the human population is significant; its impact on the delivery of healthcare is also considerable. OBJECTIVE: This article is another paper in a series addressing COVID-19-related updates to emergency clinicians on the management of COVID-19 patients with cardiac arrest. DISCUSSION: COVID-19 has resulted in significant morbidity and mortality worldwide. From a global perspective, as of February 23, 2022, 435 million infections have been noted with 5.9 million deaths (1.4%). Current data suggest an increase in the occurrence of cardiac arrest, both in the outpatient and inpatient settings, with corresponding reductions in most survival metrics. The frequency of out-of-hospital lay provider initial care has decreased while non-shockable initial cardiac arrest rhythms have increased. While many interventions, including chest compressions, are aerosol-generating procedures, the risk of contagion to healthcare personnel is low, assuming appropriate personal protective equipment is used; vaccination with boosting provides further protection against contagion for the healthcare personnel involved in cardiac arrest resuscitation. The burden of the COVID-19 pandemic on the delivery of cardiac arrest care is considerable and, despite multiple efforts, has adversely impacted the chain of survival. CONCLUSION: This review provides a focused update of cardiac arrest in the setting of COVID-19 for emergency clinicians.

Clinical update on COVID-19 for the emergency clinician: Presentation and evaluation.

INTRODUCTION: Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. OBJECTIVE: This first in a two-part series on COVID-19 updates provides a focused overview of the presentation and evaluation of COVID-19 for emergency clinicians. DISCUSSION: COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. Several variants exist, including a variant of concern known as Delta (B.1.617.2 lineage) and the Omicron variant (B.1.1.529 lineage). The Delta variant is associated with higher infectivity and poor patient outcomes, and the Omicron variant has resulted in a significant increase in infections. While over 80% of patients experience mild symptoms, a significant proportion can be critically ill, including those who are older and those with comorbidities. Upper respiratory symptoms, fever, and changes in taste/smell remain the most common presenting symptoms. Extrapulmonary complications are numerous and may be severe, including the cardiovascular, neurologic, gastrointestinal, and dermatologic systems. Emergency department evaluation includes focused testing for COVID-19 and assessment of end-organ injury. Imaging may include chest radiography, computed tomography, or ultrasound. Several risk scores may assist in prognostication, including the 4C (Coronavirus Clinical Characterisation Consortium) score, quick COVID Severity Index (qCSI), NEWS2, and the PRIEST score, but these should only supplement and not replace clinical judgment. CONCLUSION: This review provides a focused update of the presentation and evaluation of COVID-19 for emergency clinicians.

Clinical update on COVID-19 for the emergency and critical care clinician: Medical management.

INTRODUCTION: Coronavirus disease of 2019 (COVID-19) has resulted in millions of cases worldwide. As the pandemic has progressed, the understanding of this disease has evolved. OBJECTIVE: This is the second part in a series on COVID-19 updates providing a focused overview of the medical management of COVID-19 for emergency and critical care clinicians. DISCUSSION: COVID-19, caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has resulted in significant morbidity and mortality worldwide. A variety of medical therapies have been introduced for use, including steroids, antivirals, interleukin-6 antagonists, monoclonal antibodies, and kinase inhibitors. These agents have each demonstrated utility in certain patient subsets. Prophylactic anticoagulation in admitted patients demonstrates improved outcomes. Further randomized data concerning aspirin in outpatients with COVID-19 are needed. Any beneficial impact of other therapies, such as colchicine, convalescent plasma, famotidine, ivermectin, and vitamins and minerals is not present in reliable medical literature. In addition, chloroquine and hydroxychloroquine are not recommended. CONCLUSION: This review provides a focused update of the medical management of COVID-19 for emergency and critical care clinicians to help improve care for these patients.

Monkeypox: A focused narrative review for emergency medicine clinicians.

INTRODUCTION: Monkeypox is an emerging viral disease that has been declared a global health emergency. While this disease has been present for over 50 years, the recent surge in cases and expanding knowledge of this has prompted a need for a focused review for practicing clinicians. OBJECTIVE: This narrative review provides a focused overview of the epidemiology, presentation, evaluation, and management of monkeypox for emergency clinicians. DISCUSSION: Monkeypox is an orthopoxvirus endemic to central and western Africa. An outbreak in May and June 2022 across Asia, Europe, North America, and South America was declared a global health emergency in July 2022. The disease can be transmitted via contact with an infected animal or human, as well as contact with a contaminated material. The disease presents with a prodromal flu-like illness and lymphadenopathy. A rash spreading in a centrifugal manner involving the oral mucosa, face, palms, and soles is typical. Lesions progress along various stages. Complications such as bacterial skin infection, pneumonitis, ocular conditions, and encephalitis are uncommon. Confirmation typically includes polymerase chain reaction testing. The majority of patients improve with symptomatic therapy, and as of July 2022, there are no United States Food and Drug Administration-approved treatments specifically for monkeypox. However, antiviral treatment should be considered for several patient populations at risk for severe outcomes. CONCLUSION: An understanding of the presentation, evaluation, and management of monkeypox is essential for emergency clinicians to ensure appropriate diagnosis and treatment of this emerging disease.

Management of acute aortic syndromes from initial presentation to definitive treatment.

BACKGROUND: Acute aortic syndromes comprise a spectrum of diseases including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcers. Early diagnosis, rapid intervention, and multidisciplinary team care are vital to efficiently manage time-sensitive aortic emergencies, mobilize appropriate resources, and optimize clinical outcomes. OBJECTIVE: This comprehensive review outlines the multidisciplinary team approach from initial presentation to definitive interventional treatment and post-operative care. DISCUSSION: Acute aortic syndromes can be life-threatening and require prompt diagnosis and aggressive initiation of blood pressure and pain control to prevent subsequent complications. Early time to diagnosis and intervention are associated with improved outcomes. CONCLUSIONS: A multidisciplinary team can help promptly diagnose and manage aortic syndromes.

The role of generalizability in moral and political psychology.

The aim of the social and behavioral sciences is to understand human behavior across a wide array of contexts. Our theories often make sweeping claims about human nature, assuming that our ancestors or offspring will be prone to the same biases and preferences. Yet we gloss over the fact that our research is often based in a single temporal context with a limited set of stimuli. Political and moral psychology are domains in which the context and stimuli are likely to matter a great deal (Van Bavel, Mende-Siedlecki, Brady, & Reinero, 2016). In response to Yarkoni (see BBS issue), we delve into topics related to political and moral psychology that likely depend on features of the research. These topics include understanding differences between liberals and conservatives, when people are willing to sacrifice someone to save others, the behavior of political leaders, and the dynamics of intergroup conflict.

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria.

STUDY OBJECTIVE: Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm. METHODS: In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction. RESULTS: There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11). CONCLUSION: For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.