Safety and Effectiveness of Antidysrhythmic Drugs for Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation: a Systematic Review and Bayesian Network Meta-analysis.

PURPOSE: The available evidence to determine which antidysrhythmic drug is superior for pharmacologic cardioversion of recent-onset (onset within 48 h) atrial fibrillation (AF) is uncertain. We aimed to identify the safest and most effective agent for pharmacologic cardioversion of recent-onset AF in the emergency department. METHODS: We searched MEDLINE, Embase, and Web of Science from inception to February 21, 2023 (PROSPERO: CRD42018083781). Eligible studies were randomized controlled trials that enrolled adult participants with AF ≤ 48 h, compared a guideline-recommended antidysrhythmic drug with another antidysrhythmic drug or a different formulation of the same drug or placebo and reported specific adverse events. The primary outcome was immediate, serious adverse event - cardiac arrest, sustained ventricular tachydysrhythmia, atrial flutter 1:1 atrioventricular conduction, hypotension, and bradycardia. Additional analyses included the outcomes of conversion to sinus rhythm within 4 h and 24 h. We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effect model and vague prior distribution to calculate odds ratios with 95% credible intervals. We assessed confidence using CINeMA. We used surface under the cumulative ranking curve (SUCRA) to rank agent(s). RESULTS: The systematic review initially identified 5545 studies. Twenty-five studies met eligibility criteria, and 22 studies (n = 3082) provided data for NMA, which demonstrated that vernakalant (SUCRA = 70.9%) is most likely to be safest. Additional effectiveness NMA demonstrated that flecainide (SUCRA = 89.0%) is most likely to be superior for conversion within 4 h (27 studies; n = 2681), and ranolazine-amiodarone IV (SUCRA 93.7%) is most likely to be superior for conversion within 24 h (24 studies; n = 3213). Confidence in the NMA estimates is variable and limited mostly by within-study bias and imprecision. CONCLUSIONS: Among guideline-recommended antidysrhythmic drugs, the combination of digoxin IV and amiodarone IV is definitely among the least safe for cardioversion of recent onset AF; flecainide, vernakalant, ibutilide, propafenone, and amiodarone IV are definitely among the most effective for cardioversion within 4 h; flecainide is definitely among the most effective for cardioversion within 24 h. Further, randomized controlled trials with predetermined and strictly defined, hemodynamic adverse event outcomes are recommended.

Transcutaneous electrical nerve stimulation (TENS) versus sham TENS in adult ED patients with abdominal pain: A clinical trial.

OBJECTIVE: There is a growing consensus that the risks of current pharmacologic analgesics warrant consideration of alternative modalities for acute and chronic pain control. The objective of this study was to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in adult emergency department (ED) patients presenting with abdominal pain. METHODS: We conducted a patient and observer blinded randomized controlled trial comparing TENS to sham TENS. The study was conducted at a large suburban academic ED. Patients with abdominal pain and a verbal numeric pain scale (VNS) of 5 or greater were randomized to TENS or sham TENS applied via 4 skin pads, one in each abdominal quadrant for 30 min. The primary outcome was change in pain scores 30 min after the intervention. Our study had 80% power to detect a between group difference of 1.5 points on the VNS. RESULTS: 81 patients were randomized to TENS (n = 41) or sham TENS (n = 40). Groups were similar in baseline characteristics. The mean (SD) reductions in pain scores were 1.9 (2.1) and 1.7 (2.6) in patients treated with TENS and sham TENS respectively (P = 0.81). Use of rescue medications in patients with treated with TENS and sham TENS was similar (49 vs 55% respectively, P = 0.66). CONCLUSIONS: Application of TENS to the abdominal wall did not result in more effective pain relief than sham TENS in adult ED patients with abdominal pain.

Introduction of a high sensitivity troponin reduces ED length of stay.

BACKGROUND: High sensitivity cardiac troponins (hs-cTn) allow earlier identification and exclusion of acute myocardial infarction. We determined if transitioning from contemporary to high sensitivity troponin T (hs-cTnT) would reduce ED length of stay in chest pain (CP) patients. METHODS: We conducted a pragmatic, prospective, before and after study of implementing a hs-cTnT by reviewing the electronic health records in all adult ED patients presenting to a large, suburban academic medical center during the 3 months before and after transitioning from a 4th generation troponin to a 5th generation hs-cTnT (Elecsys® Troponin T-high sensitive, Roche Diagnostics, Indianapolis, IN). RESULTS: There were 1431 and 1437 CP patients before and after the intervention. Mean (SD) age was 51.5 (18) yrs. and 54.3% were female. The median (IQR) ED LOS for chest pain patients directly discharged to home was 6.2 (4.7-8.4) and 5.3 (4.0-7.2) hours before and after introducing hs-cTn respectively; difference 47 min (95%CI, 35-59); P < 0.001. The median (IQR) ED LOS for chest pain patients admitted to the hospital was 9.5 (6.6-13.8) and 8.1 (5.7-11.2) hours before and after introducing hs-cTn respectively; difference 77 min (95%CI, 35-121); P < 0.001. Overall admission rates (22 vs 21% both before and after) did not change during the study. The rates of computed tomography coronary angiography before and after the intervention were 21 and 20.4% respectively. The rates of invasive coronary angiography before and after the intervention were 5.8 and 5.6% respectively. CONCLUSIONS: Transitioning to a hs-cTnT is associated with a clinically relevant and statistically significant reduction in ED LOS for both discharged and admitted patients with and without CP with no increase in admission or coronary angiography rates.

Informal Peer Support and Intentional Acts of Kindness May Attenuate the Impact of Work-Related Stressors on Compassion Satisfaction, Secondary Traumatic Stress, and Burnout of Emergency Medical Services Clinicians.

OBJECTIVE: Emergency medical services (EMS) Code Lavender was developed to support EMS clinicians after stressful events via consistent recognition of events, informal peer support, and intentional acts of kindness. This study evaluated changes in burnout screening tool responses of EMS clinicians in response to program implementation and the coincidental start of coronavirus disease 2019. METHODS: Anonymous surveys with demographic questions and 2 burnout screening tools were distributed before program implementation (spring 2020) and 20 months later (fall 2021). Analysis included t-tests, Fisher exact tests, and multivariable linear regression. RESULTS: Seventy-seven preprogram (59% response rate) and 108 intraprogram (88% response rate) survey responses were included. No changes existed between preprogram and intraprogram responses across all subscale scores. Sex was associated with depersonalization subscale scores, with men having scores 1.53 (95% confidence interval [CI] 0.11-2.95) higher than women. Compared with emergency medical technicians, paramedics had higher compassion satisfaction (OR 3.50; 95% CI 1.79-5.70) and personal accomplishment scores (OR 2.40; 95% CI 1.08-3.71). Transport nurses had higher personal accomplishment (OR 3.29; 95% CI 1.18-5.40), depersonalization (OR 3.73; 95% CI 1.19-6.26), and rates of burnout symptoms (OR 0.54; 95% CI 0.09-0.98) than emergency medical technicians. CONCLUSION: The organizational commitment, peer support, and authentic leadership of EMS Code Lavender may attenuate work-related stressors among EMS clinicians.

Supporting Emergency Medical Services Clinicians Through Acute and Sustained Crises With Informal Peer Support and Intentional Acts of Kindness: The Emergency Medical Services Code Lavender Program.

OBJECTIVE: Given the recommendations against the use of critical incident stress debriefing, the emergency medical services (EMS) Code Lavender program was created as a mechanism to consistently recognize and reach out to EMS clinicians after acute crisis events, offer nonintrusive informal peer support and acts of kindness, and provide stepwise support via mental health professionals as needed. The study aimed to assess program utilization and evaluate the program's impact on EMS clinicians' perceptions of support and resources available to them after an acute crisis event. METHODS: Anonymous surveys were distributed before program implementation and 18 months later. Program utilization was tracked using REDCap (Vanderbilt University, Nashville, TN). Fisher exact tests and logistic regression were used to analyze the survey results. RESULTS: Within 30 months, 87 referrals were made. Seventy-seven preprogram (59% response rate) and 104 intraprogram (88% response rate) surveys were collected. There were no differences between respondents by sex or role. There were significant improvements in knowing where to go for help (from 40% to 85%, P < .001) and willingness to seek help if needed (from 40% to 59%, P = .02). CONCLUSION: The implementation of an EMS Code Lavender program led to significant increases in EMS clinician self-reported knowledge of where to go and willingness to seek help after acute crisis events.

Analgesic use in ED patients with long-bone fractures: A national assessment of racial and ethnic disparities.

BACKGROUND: It is vital to ensure equitable care is given to all patients and to eliminate any disparities in administration of analgesics and opioids in emergency department (ED) patients with long-bone fractures. Our objective was to determine whether sex, ethnic, or racial disparities still exist in administration and prescription of analgesics and opioids in ED patients with long-bone fractures using a current nationally representative database. METHODS: This was a retrospective, cross-sectional analysis of ED patients ages 15-55 years with long-bone fractures included in the National Hospital and Medical Care Survey (NHAMCS) database from 2016 to 2019. Our primary and secondary outcomes were administration of analgesics and opioids in the ED and our exploratory outcomes were prescription of analgesics and opioids in discharged patients. Outcomes were adjusted for age, sex, race, insurance, fracture location, number of fractures, and pain severity. RESULTS: Of the estimated 2.32 million ED patient visits analyzed, 65% received analgesics and 50% received opioids in the ED. On multivariable analyses, administration of analgesics was associated with female sex (OR 2.11; 95% CI 1.08-4.12) and Black race (OR 2.84; 95% CI 1.03-7.80), but not with Hispanic/Latino ethnicity (OR 2.09; 95% CI 0.72-6.04). No associations were found between opioid administration or analgesic or opioid prescription and female sex, Hispanic/Latino ethnicity, or Black race. CONCLUSIONS: Between 2016 and 2019 there were no significant sex, ethnic, or racial disparities in administration or prescription of analgesics or opioids in ED adult patients with long-bone fractures.

The role of point-of-care testing in cardiac arrest patients.

BACKGROUND: Point-of-care testing (POCT) provides real time information to the clinical team, leading to early diagnosis and treatment. Whether POCT plays a role in improving outcomes in patients with out of hospital cardiac arrest (OHCA) remains unknown. The objective of this study was to describe use of POCT in OHCA and to explore its association with outcomes. METHODS: We conducted a retrospective chart review on patients transferred by emergency medical services (EMS) to the ED for out-of-hospital cardiac arrest (OHCA) in 2019. Data collected from patient charts included baseline information, the Utstein criteria for cardiac arrest, whether POCT was used, whether POCT was abnormal, and what treatment was given, if any, as a result of the abnormal POCT. Outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge. Outcomes in patients with and without POCT were compared using chi-square and t-tests. RESULTS: There were 119 study patients. Their mean (SD) age was 65 (18) years and 65% were male. Cardiac arrest was witnessed in 48% and initial rhythm was asystole in 66%. The rates of ROSC and survival were 22.7% (95%CI, 16.1-31.1) and 3.4% (95%CI, 1.3-8.3). POCT was used in 66 patients (55.4%; 95%CI, 46.5-64.1) all of whom had at least one abnormality. The results of POCT led to administration of a therapy in 60 patients (91.0%; 95%CI, 81.6-95.8). The rates of ROSC in patients with and without POCT were 22.6% vs 22.7% respectively. The rates of survival to discharge in patients with and without POCT were 0% vs 3.8% respectively. CONCLUSIONS: POCT is commonly used in the ED for patients with OHCA and its results often lead to changes in therapies. However, use of POCT was not associated with ROSC or survival to discharge.

FOCUS may detect wall motion abnormalities in patients with ACS.

BACKGROUND: Chest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department. PURPOSE: We sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients. METHODS: We performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training. RESULTS: FOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82-98), specificity 35% (95% CI, 15-61), and overall accuracy of 78% (95% CI, 66-87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64-96), a specificity of 56% (95% CI, 23-85%), and an accuracy of 77 (95% CI, 58-90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64-95%), a specificity of 75% (95% CI, 36-96%), and an accuracy of 82% (95% CI, 65-93%). CONCLUSIONS: Our retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.

Bacterial infections and death among patients with Covid-19 versus non Covid-19 patients with pneumonia.

BACKGROUND: Many patients with Coronavirus disease-2019 (Covid-19) present with radiological evidence of pneumonia. Because it is difficult to determine co-existence of bacterial pneumonia, many of these patients are initially treated with antibiotics. We compared the rates of bacterial infections and mortality in Covid-19 patients with pulmonary infiltrates versus patients diagnosed with 'pneumonia' the year previously. METHODS: We conducted a medical record review of patients admitted with Covid-19 and a pulmonary infiltrate and compared them with patients diagnosed with pneumonia admitted in the prior year before the pandemic. Data abstracted included baseline demographics, comorbidities, signs and symptoms, laboratory and microbiological results, and imaging findings. Outcomes were bacterial infections and mortality. Patients presenting with and without Covid-19 were compared using univariable and multivariable analyses. RESULTS: There were 1398 and 1001 patients admitted through the emergency department (ED) with and without Covid-19 respectively. Compared with non-Covid-19 patients, those with Covid-19 were younger (61±18 vs. 65±25 years, P < 0.001) and had a lower Charlson Comorbidity Index (0.7 vs. 1.2, P < 0.001). Bacterial infections were present in fewer Covid-19 than non-Covid-19 patients (8% vs. 13%, P < 0.001), and most infections in Covid-19 were nosocomial as opposed to community acquired in non-Covid-19 patients. CXR was more often read as abnormal and with bilateral infiltrates in patients with Covid-19 (82% vs. 70%, P < 0.001 and 81% vs. 48%, P < 0.001, respectively). Mortality was higher in patients with Covid-19 vs. those without (15% vs. 9%, P < 0.001). Multivariable predictors (OR [95%CI]) of mortality were age (1.04 [1.03-1.05]/year), tachypnea (1.55 [1.12-2.14]), hypoxemia (2.98 [2.04-4.34]), and bacterial infection (2.80 [1.95-4.02]). Compared with non-Covid-19 patients with pneumonia, patients with Covid-19 were more likely to die (2.68 [1.97-3.63]). CONCLUSIONS: The rate of bacterial infections is lower in Covid-19 patients with pulmonary infiltrates compared with patients diagnosed with pneumonia prior to the pandemic and most are nosocomial. Mortality was higher in Covid-19 than non-Covid-19 patients even after adjusting for age, tachypnea, hypoxemia, and bacterial infection.

Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis.

BACKGROUND: Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). METHODS: The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. RESULTS: Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. CONCLUSIONS: Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.

Survival of COVID-19 Patients With Respiratory Failure is Related to Temporal Changes in Gas Exchange and Mechanical Ventilation.

Background: Respiratory failure due to coronavirus disease of 2019 (COVID-19) often presents with worsening gas exchange over a period of days. Once patients require mechanical ventilation (MV), the temporal change in gas exchange and its relation to clinical outcome is poorly described. We investigated whether gas exchange over the first 5 days of MV is associated with mortality and ventilator-free days at 28 days in COVID-19. Methods: In a cohort of 294 COVID-19 patients, we used data during the first 5 days of MV to calculate 4 daily respiratory scores: PaO2/FiO2 (P/F), oxygenation index (OI), ventilatory ratio (VR), and Murray lung injury score. The association between these scores at early (days 1-3) and late (days 4-5) time points with mortality was evaluated using logistic regression, adjusted for demographics. Correlation with ventilator-free days was assessed (Spearman rank-order coefficients). Results: Overall mortality was 47.6%. Nonsurvivors were older (P < .0001), more male (P = .029), with more preexisting cardiopulmonary disease compared to survivors. Mean PaO2 and PaCO2 were similar during this timeframe. However, by days 4 to 5 values for all airway pressures and FiO2 had diverged, trending lower in survivors and higher in nonsurvivors. The most substantial between-group difference was the temporal change in OI, improving 15% in survivors and worsening 11% in nonsurvivors (P < .05). The adjusted mortality OR was significant for age (1.819, P = .001), OI at days 4 to 5 (2.26, P = .002), and OI percent change (1.90, P = .02). The number of ventilator-free days correlated significantly with late VR (-0.166, P < .05), early and late OI (-0.216, P < .01; -0.278, P < .01, respectively) and early and late P/F (0.158, P < .05; 0.283, P < .01, respectively). Conclusion: Nonsurvivors of COVID-19 needed increasing intensity of MV to sustain gas exchange over the first 5 days, unlike survivors. Temporal change OI, reflecting both PaO2 and the intensity of MV, is a potential marker of outcome in respiratory failure due to COVID-19.

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective.

OBJECTIVES: Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone. METHODS: We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables. RESULTS: From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93). CONCLUSIONS: ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

The role of emergency department computed tomography in early acute pancreatitis.

INTRODUCTION: Computed tomography (CT) is often ordered for patients in whom the diagnosis of acute pancreatitis (AP) has already been established via elevated lipase levels and typical abdominal pain. We investigated whether early CT imaging performed in the ED altered the diagnosis or management. METHODS: A retrospective chart review was performed on patients presenting to a large, academic ED between the years 2013-2015 with AP who received CT imaging. Relevant history, laboratory, imaging data, and hospital course were abstracted from the medical record and analyzed by three independent reviewers, with 100% agreement among reviewers on 30 randomly selected cases. The primary outcome was whether the CT led to a change in diagnosis or management above and beyond the ultrasound. Univariate and multivariate analyses were performed to determine association between predictor variables and outcomes. RESULTS: The electronic health record query yielded 458 patients. Of those, 174 met the American College of Gastroenterology criteria for AP and were included in the study. 145 patients (83%) had abdominal CT during their hospital course, 125 (86%) of which were performed in the ED. Of these 145 patients, 57 (39%) had imaging evidence of AP. 107 patients had abdominal ultrasound (US) during their hospital course. Of 84 patients who had both CT and US, 31 (37%) patients were diagnosed with gallstones by US versus 19 (23%) by CT. Biliary dilation/obstruction was diagnosed by US in 5 (6%) patients versus 4 (5%) by CT. CT led to the correct diagnosis or change in management in 21 (14.5%) patients. CONCLUSION: Early CT may alter the diagnosis or management in up to 15% of patients presenting to the ED with AP, especially older patients with prior episodes of pancreatitis and biliary interventions, however abdominal US may be a more sensitive screening study for biliary etiologies and thereby better direct further management.

Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI.

BACKGROUND: The current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI). OBJECTIVE: We aimed to compare the two paradigms within a single population. We hypothesized that STEMI(-) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization. METHODS: We performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0-2 flow or TIMI 3 flow plus peak troponin T > 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes. RESULTS: Among 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(-) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18-7.63), 1.87 (IQR 1.12-5.48), and 0.00 (IQR 0.00-0.08). Median time from arrival to catheterization was 41 min (IQR 23-86 min) for STEMI(+) OMI compared with 437 min (IQR 85-1590 min) for STEMI(-) OMI (p < 0.001). STEMI(+) OMI was more likely than STEMI(-) OMI to undergo catheterization within 90 min (76% vs. 28%; p < 0.001). CONCLUSIONS: STEMI(-) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(-) OMI.

The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients.

STUDY OBJECTIVE: Midline catheters are an alternative to more invasive types of vascular access in patients in whom obtaining peripheral access has proven difficult. Little is known of the safety and utility of midline catheters when used more broadly in critically ill patients in the emergency department (ED). These are long peripheral catheter, ranging from 10 to 25 cm in length, typically placed with assistance of ultrasound and the Seldinger's technique. We describe our experience with the use of midline catheters in the ED. METHODS: We conducted a prospective observational case series of all patients who had a midline catheter insertion attempted in the ED. We prospectively captured data on indication, technique, location, catheter type, number of attempts, overall success or failure, vasoactive use, and complications (daily catheter patency, flow, site appearance, and dwell-time complications). RESULTS: From January 28, 2016, to December 30, 2017, practitioners placed 403 midline catheters. Catheter insertion success was 99%, and the median number of attempts was 1 (interquartile range 1 to 1; minimum 1; maximum 3). The median number of days the catheter remained in place was 5 (interquartile range 2 to 8). Failure to aspirate occurred in 57 patients (14%; 95% confidence interval 11% to 18%). Overall, 10 patients (2.5%; 95% confidence interval 1.2% to 4.5%) experienced 10 insertion-related complications. During the study period, 49 patients (12%; 95% confidence interval 9% to 16%) experienced 60 dwell-time-related complications. Severe complications occurred in 3 patients (0.7%). CONCLUSION: Midline catheters may present a feasible alternative to central venous access in certain critically ill ED patients.

Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort.

STUDY OBJECTIVE: Shoulder dislocations are a common injury leading to emergency department presentations. Point-of-care ultrasonography has the potential to reduce radiation and time to diagnosis. We determine the accuracy of a novel point-of-care ultrasonographic technique to diagnose dislocated shoulders. We also investigate its accuracy to detect fractures, time to image acquisition, the optimal cutoff for the glenohumeral distance, and compare the time to diagnose dislocations from triage between point-of-care ultrasonography and radiography. METHODS: This was a multicenter prospective observational study. Ultrasonography fellows and fellowship-trained physicians enrolled a convenience sample of patients with suspected shoulder dislocation. Point-of-care ultrasonography was performed with a novel posterior approach with either a curvilinear or a linear transducer. Shoulder dislocation was confirmed with a 3-view radiograph interpreted by an independent radiologist. Sensitivity, specificity, positive predictive values, and negative predictive values were determined for point-of-care ultrasonography, with radiography as the criterion standard. Time to image acquisition, presence or absence of fracture, glenohumeral distance, sonographer confidence, and difference in time to diagnosis from triage for point-of-care ultrasonography and radiograph were also determined. A second investigator independently reviewed all images and interobserver agreement was calculated. RESULTS: Sixty-five patients were enrolled in the study. The sensitivity and specificity of point-of-care ultrasonography for identifying dislocations were 100% (95% confidence interval [CI] 87% to 100%) and 100% (95% CI 87% to 100%), respectively. Point-of-care ultrasonography was 92% sensitive (95% CI 60% to 99.6%) and 100% specific (95% CI 92% to 100%) for non-Hill-Sachs/Bankart's fractures of the humerus. Point-of-care ultrasonography was faster from triage than standard radiology in diagnosing dislocations (median difference 43 minutes; interquartile range [IQR] 23 to 60 minutes). The median total time required for diagnosis by point-of-care ultrasonography was 19 seconds (IQR 10 to 36 seconds). The median glenohumeral distance was -1.83 cm (IQR -1.98 to -1.41 cm) in anterior dislocations, 0.22 cm (IQR 0.10 to 0.35 cm) on nondislocated shoulders, and 3.30 cm (IQR 2.59 to 4.00 cm) in posterior dislocations. CONCLUSION: A posterior approach point-of-care ultrasonographic study is a quick and accurate tool to diagnose dislocated shoulders. Ultrasonography was also able to accurately identify humeral fractures and significantly reduce the time to diagnosis from triage compared with standard radiography.

Cohort of Four Thousand Four Hundred Four Persons Under Investigation for COVID-19 in a New York Hospital and Predictors of ICU Care and Ventilation.

Study objective: Most coronavirus disease 2019 (COVID-19) reports have focused on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients. However, at initial presentation, most patients' viral status is unknown. Determination of factors that predict initial and subsequent need for ICU and invasive mechanical ventilation is critical for resource planning and allocation. We describe our experience with 4,404 persons under investigation and explore predictors of ICU care and invasive mechanical ventilation at a New York COVID-19 epicenter. Methods: We conducted a retrospective cohort study of all persons under investigation and presenting to a large academic medical center emergency department (ED) in New York State with symptoms suggestive of COVID-19. The association between patient predictor variables and SARS-CoV-2 status, ICU admission, invasive mechanical ventilation, and mortality was explored with univariate and multivariate analyses. Results: Between March 12 and April 14, 2020, we treated 4,404 persons under investigation for COVID-19 infection, of whom 68% were discharged home, 29% were admitted to a regular floor, and 3% to an ICU. One thousand six hundred fifty-one of 3,369 patients tested have had SARS-CoV-2-positive results to date. Of patients with regular floor admissions, 13% were subsequently upgraded to the ICU after a median of 62 hours (interquartile range 28 to 106 hours). Fifty patients required invasive mechanical ventilation in the ED, 4 required out-of-hospital invasive mechanical ventilation, and another 167 subsequently required invasive mechanical ventilation in a median of 60 hours (interquartile range 26 to 99) hours after admission. Testing positive for SARS-CoV-2 and lower oxygen saturations were associated with need for ICU and invasive mechanical ventilation, and with death. High respiratory rates were associated with the need for ICU care. Conclusion: Persons under investigation for COVID-19 infection contribute significantly to the health care burden beyond those ruling in for SARS-CoV-2. For every 100 admitted persons under investigation, 9 will require ICU stay, invasive mechanical ventilation, or both on arrival and another 12 within 2 to 3 days of hospital admission, especially persons under investigation with lower oxygen saturations and positive SARS-CoV-2 swab results. This information should help hospitals manage the pandemic efficiently.

Are Stroke Survivors Discharged to the Recommended Postacute Setting?

OBJECTIVE: To examine the processes and barriers involved in providing postdischarge stroke care. DESIGN: Prospective study of discharge planners' (DP) and physical therapists' (PT) interpretation of factors contributing to patients' discharge destination. SETTING: Twenty-three hospitals in the northeastern United States. PARTICIPANTS: After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. RESULTS: In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). CONCLUSIONS: Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Rapid correction of hyperkalemia is associated with reduced mortality in ED patients.

BACKGROUND: Hyperkalemia (HK) is common and associated with mortality. Our purpose was to determine if the rapid correction of elevated serum potassium level (K+) was associated with reduced mortality in emergency department (ED) patients. METHODS: Design: We reviewed the electronic medical records (EMR) of ED patients with HK (K+ ≥ 5.5 mEq/L) from 10/2016-10/2017. SETTING: Large, academic ED. PARTICIPANTS: Adult ED patients presenting with hyperkalemia. Main outcomes and measures: The main outcome was in-hospital mortality. We compared outcomes of patients whose K+ normalized (dropped below 5.5 mEq/L) with those whose K+ did not normalize using chi-square and multivariate analyses to determine the associations between predictor variables and outcomes. RESULTS: From 114,977 ED visits, 1033 patients (0.9%, 95%CI 0.85-0.95%) had HK. Their mean (SD) age was 60 (26) years and 58% were male. Of these, 884 had a second K+ measured within a median (IQR) of 5 (3-8) hours. Mortality and admission rates were higher in patients with HK vs. those with normal K+ (8.5% vs. 0.8%, P < 0.001 and 80% vs. 39%, P < 0.001, respectively). Mortality was lower in patients whose HK normalized compared with those whose K+ remained elevated (6.3% vs. 12.7%, P = 0.001). After adjusting for age, creatinine, comorbidities, and initial K+, normalization of K+ was associated with reduced mortality (OR 0.47, 95%CI 0.28 to 0.80). CONCLUSIONS: Normalization of K+ during the ED stay in patients with HK is associated with a 50% mortality reduction. Efforts to rapidly identify and treat HK in the ED are needed.

Relationship between body temperature and heart rate in adults and children: A local and national study.

BACKGROUND: A patient's vital signs are all inextricably interrelated, and together provide critical information regarding hemodynamic and physiological status. Yet, the precise relationship between body temperature (T) and heart rate (HR) in adults remains a fundamental gap in our knowledge. METHODS: We performed a retrospective secondary analysis of (1) electronic medical records from a large academic center (annual ED census of 110,000) and (2) the National Hospital Ambulatory Medical Care Survey (NHAMCS), a large CDC-sponsored weighted sample of U.S. EDs and our own large tertiary care ED, extracting demographic and clinical data including vital signs. RESULTS: We included 8715 local ED visits and approximately 123.3 million estimated national adult ED visits. Mean T was 36.9 °C, and 5.2% of patients had a T over 38 °C. Mean (SD) HR was 93.3 bpm, 28% had a HR over 100 bpm. Males had significantly lower HR than females (coefficient -1.6, 95%CI -2.4 to -0.8), while age was negatively associated with HR (coefficient -0.08, 95%CI -0.10 to -0.06). For national data, an increase of 1 °C in T corresponded to an increase in HR of 7.2 bpm (95%CI 6.2 to 8.3). After adjusting for age and gender, a 1 °C increase in T corresponded to a mean (95%CI) 10.4 (9.5-11.4) and 6.9 (5.9-7.8) increase in HR locally and nationally, respectively. CONCLUSIONS: Among adult ED patients nationally, for every increase in T of 1 °C, the HR increases by approximately 7 bpm.