Balanced Crystalloids versus Saline in Noncritically Ill Adults.

BACKGROUND: Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU). METHODS: We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first. RESULTS: A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01). CONCLUSIONS: Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT-ED ClinicalTrials.gov number, NCT02614040 .).

A model for rapid emergency department expansion for the COVID-19 pandemic.

COVID-19 has caused global dramatic change in medical practices including the introduction of temporary screening and assessment areas outside the footprint of the main hospital structures. Following the initial surge of patients with novel coronavirus (2019-nCoV) in the United States, our medical center rapidly designed and constructed an alternative assessment and treatment site in a converted parking garage deck for emergency department patients with suspected or confirmed 2019-nCoV. During the first month after opening, 651 patients were treated in this alternative assessment area including 54 patients who tested positive for 2019-nCoV. This accounted for 55% of the 98 patients with confirmed novel coronavirus (2019-nCoV) who were treated in our ED. This report provides a blueprint for the necessary steps, materials, labor needs and barriers, both anticipated and unanticipated, to rapidly construct an alternative ED treatment site during a pandemic.

Pre-Arrival Care of the Out-of-Hospital Cardiac Arrest Victim.

Lay rescuers play a pivotal role in the recognition and initial management of out-of-hospital cardiac arrest. The provision of timely pre-arrival care by lay responders, including cardiopulmonary resuscitation and the use of automated external defibrillator before emergency medical service arrival, is important link in the chain of survival and has been shown to improve outcomes from cardiac arrest. Although physicians are not directly involved in bystander response to cardiac arrest, they play a key role in emphasizing the importance of bystander interventions.

Assessment of the Framingham risk factors among ED patients with newly diagnosed atrial fibrillation.

STUDY OBJECTIVE: Atrial fibrillation (AF) is often first diagnosed in the emergency department (ED) and accounts for nearly 1% of all emergency department (ED) visits. Our objective was to assess the Framingham Heart Study risk score for AF development in ED patients with newly diagnosed AF. METHODS: We systematically reviewed the electronic medical records of ED patients with newly diagnosed AF between August 2005 and July 2008. We measured the frequency of the Framingham Heart Study predictors and calculated each patient's risk score. RESULTS: During the 3-year study period, 914 patients had 1228 ED visits. New AF was diagnosed in 296 (32%) patients. Among these patients, 107 (36%) were female, 127 (43%) had prior ED visits since 2003, 189 (64%) were taking hypertension medications and 170 (57.4%) had previous electrocardiograms with measurable PR intervals. The median PR interval was 166 ms (151 to 180) and 60% of available PR intervals were 160 ms or greater. The median (interquartile range) age, body mass index, and systolic blood pressure were 66 years (53-77), 27 (23-31), and 134 mm Hg (118-151), respectively. Median risk score was 7 (3-9) indicating high predicted risk. Heart failure and cardiac murmurs were previously diagnosed in 45 (15%) and 32 (11%) of these patients, respectively. CONCLUSIONS: The Framingham risk factors for AF are commonly encountered among ED patients with newly diagnosed AF. The ED might provide an opportunity to identify patients at high risk for AF and refer them for primary prevention interventions.

Predictors of ambulance transport in patients with ST-elevation myocardial infarction.

INTRODUCTION: Despite intense public awareness campaigns, many patients with ST-elevation myocardial infarction (STEMI) do not utilize Emergency Medical Services (EMS) transportation to the Emergency Department (ED). Predictors for mode of transport by EMS versus private vehicle in patients with an acute STEMI were investigated. Hypothesis It was hypothesized that patient characteristics, specifically older age, male sex, and a history of a prior cardiac intervention, would be associated with a higher likelihood of EMS utilization. METHODS: A retrospective, observational cohort study was performed for all STEMI patients treated from April 1, 2007 through June 30, 2010 at an urban, academic ED with 24-hour cardiac catheterization available. Multivariable analyses with predetermined predictors (age, sex, prior cardiac intervention, weekend/evening arrival) were performed to investigate associations with mode of transport. Door-to-balloon (D2B) times were calculated. RESULTS: Of the 209 STEMI patients, 11 were excluded, leaving 198 for analysis. Median age was 60 years (IQR: 53-70), 138 (70%) arrived by private vehicle, and 60 (30%) by EMS. The primary analysis did not identify significant predictors for EMS, but a post-hoc model found that private insurance (OR 0.18; 95% CI, 0.07-0.45) was associated with fewer EMS transports. Although not statistically significant due to the great variability in time of arrival for STEMI patients transported by private vehicle, EMS transports had shorter D2B times. During business hours and weekend/evenings, EMS had D2B times of 50 (IQR: 42-61) and 58 minutes (IQR: 47-63), respectively, while private vehicle transports had median D2B times of 62 (IQR: 50-74) and 78 minutes (IQR: 66-106). Conclusion No associations between mode of transport and patient age, sex, weekend/evening presentation and history of a prior cardiac intervention were identified. Privately insured patients were less likely to use EMS when experiencing a STEMI. More effective ways are needed to educate the public on the importance of EMS activation when one is concerned for acute coronary syndrome.

A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults.

OBJECTIVES: The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults. METHODS: This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes. RESULTS: Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were -22 (-32 to -15), -30 (-38 to -25.5), -29 (-40 to -21), and -16 (-25 to -3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were -8 (-18.5 to 3), -7 (-21 to -5.5), and 6 (-7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16). CONCLUSIONS: Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.

Placing physician orders at triage: the effect on length of stay.

STUDY OBJECTIVE: Emergency department (ED) crowding is a significant problem nationwide, and numerous strategies have been explored to decrease length of stay. Placing a physician in the triage area to rapidly disposition low-acuity patients and begin evaluations on more complex patients is one strategy that can be used to lessen the effect of ED crowding. The goal of this study is to assess the effect of order placement by a triage physician on length of stay for patients ultimately treated in a bed within the ED. METHODS: We conducted a pre-experimental study with retrospective data to evaluate patients with and without triage physician orders at a single academic institution. A matched comparison was performed by pairing patients with the same orders and similar propensity scores. Propensity scores were calculated with demographic and triage data, chief complaint, and ED capacity on the patient's arrival. RESULTS: During the 23-month study period, a total of 66,909 patients were sent to the waiting room after triage but still eventually spent time in an ED bed. A quarter of these patients (23%) had physician orders placed at triage. After a matched comparison, patients with triage orders had a 37-minute (95% confidence interval 34 to 40 minutes) median decrease in time spent in an ED bed, with an 11-minute (95% confidence interval 7 to 15 minutes) overall median increase in time until disposition. CONCLUSION: Our study suggests that early orders placed by a triage physician have an effect on ED operations by reducing the amount of time patients spend occupying an ED bed.

Emergency medical services transport decisions in posttraumatic circulatory arrest: are national practices congruent?

OBJECTIVE: To catalog the 9-1-1 emergency medical services (EMS) transport practices for posttraumatic circulatory arrest patients (PTCAPs) in the majority of the nation's largest municipalities and to compare those practices to guidelines recommended by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACSCOT). METHODS: A survey was conducted in 33 of the nation's largest cities primarily to determine whether or not individual EMS systems transport PTCAPs to hospitals and, if so, whether or not the initial electrocardiographic (ECG) rhythm or mechanism of injury affected those transport decisions. RESULTS: All 33 cities (100%) responded. Seven (21%) indicated that EMS would transport an "asystolic blunt trauma patient" emergently or "leave the transport decision to paramedic judgment" despite NAEMSP-ACSCOT guidelines to terminate resuscitation in such cases. Likewise, 15 (46%) of the 33 EMS agencies would transport "asystolic penetrating trauma patients" emergently. Similarly, 27 (82%) would transport penetrating injury patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses. However, only five systems had policies that included a minimum ECG heart rate criterion for transport, and all agencies that monitor ECG (n = 32) would transport PTCAPs found with ventricular fibrillation. CONCLUSIONS: Many of the nation's highest volume EMS systems transport certain PTCAPs emergently, contrary to NAEMSP-ACSCOT guidelines to terminate resuscitative efforts in such cases. Reasons for these discrepancies should be evaluated to help better delineate applicable consensus guidelines for large urban EMS agencies.

Resident involvement in civilian tactical emergency medicine.

BACKGROUND: Tactical emergency medicine services (TEMS) has emerged as a specialized niche within the field of emergency medicine. With increasing demand for physician participation in civilian tactical teams, there will be efforts by residents to become involved at earlier points in their clinical training. OBJECTIVES: This article discusses resident involvement with a civilian TEMS unit and provides five maxims for emergency physicians to better understand the difference between working in the emergency department or with emergency medical services vs. in a TEMS environment. DISCUSSION: Differences between TEMS and other trauma life support models, institutional and political barriers likely to be encountered by the resident, the value of preventive medicine and the role of the physician in long-term tactical operations, opportunities for subspecialty growth, and the role of operational security are all discussed in detail. CONCLUSION: Tactical emergency medicine is a specialty that utilizes the full array of the emergency physician's skill set. It is also a field that is ripe for continued expansion, but the resident looking to become involved with a team should be aware of the requirements necessary to do so and the obstacles likely to be encountered along the way.

Evolving AMI care, 2010.

The care of the patient with an acute coronary syndrome, specifically STEMI, continues to evolve. Although the goal of caring for any patient with STEMI is a D2B time of less than 90 minutes, research shows that every minute counts, and "time is muscle". Thus, even if a hospital has an acceptable D2B time, EMS on-scene and transport times must be minimized to ensure optimal treatment and recovery of a dying heart. All EMS systems should work with their destination hospitals to ensure E2B times are optimally lowered and aim for an E2B of under 90 minutes when possible. MOreover, a team approach to PCI activation involving both the paramedic and ED physician whenever possible appears to be the best way to decrease false activations and increase recognition of STEMI patients. As research into myocardial infarction and treatment continues, EMS personnel should expect more critical care transports of patients who have already received lytic therapy. The in-hospital care of patients with acute coronary syndromes continues to evolve, and similarly EMS care for ACS patients continues to change at an ever-increasing rate.

Diabetic hyperglycemic emergencies: a systematic approach

For patients presenting with suspected diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) understanding of the etiology and pathophysiology will ensure optimal emergency management. Morbidity and mortality is most often due to the underlying precipitating cause, which may include infection, infarction/ischemia, noncompliance with insulin therapy, pregnancy, and dietary indiscretion. Current guidelines are based primarily on expert opinion and consensus statements, but more recent evidence suggests that recommendations related to arterial blood gas, insulin bolus, and IV fluid replacement should be re-evaluated. This issue presents an approach to DKA and HHS management based on current evidence, with a simplified pathway for emergency department management.