The Effect of Early Severe Hyperoxia in Adults Intubated in the Prehosptial Setting or Emergency Department: A Scoping Review.

BACKGROUND: The detrimental effects of hyperoxia exposure have been well-described in patients admitted to intensive care units. However, data evaluating the effects of short-term, early hyperoxia exposure in patients intubated in the prehospital setting or emergency department (ED) have not been systematically reviewed. OBJECTIVE: Our aim was to quantify and describe the existing literature examining the clinical outcomes in ED patients exposed to hyperoxia within the first 24 h of mechanical ventilation. METHODS: This review was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Two rounds of review using Rayyan QCRI software were performed for title and abstract screening and full-text search. Of the 2739 articles, 27 articles were retrieved after initial screening, of which 5 articles were excluded during the full-text screening, leaving 22 articles for final review and data extraction. RESULTS: Of 22 selected publications, 9 described patients with traumatic brain injury, 6 with cardiac arrest, 3 with multisystem trauma, 1 with stroke, 2 with septic shock, and 1 was heterogeneous. Three studies were randomized controlled trials. The available data have widely heterogeneous definitions of hyperoxia exposure, outcomes, and included populations, limiting conclusions. CONCLUSIONS: There is a paucity of data that examined the effects of severe hyperoxia exposure in the acute, post-intubation phase of the prehospital and ED settings. Further research with standardized definitions is needed to provide more detailed guidance regarding early oxygen titration in intubated patients.

External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools.

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).

Multi-center implementation of automated age-adjusted D-dimer results reduces unnecessary PE imaging.

BACKGROUND: Several previous studies have investigated the clinical utility of age-adjusted D-dimer cutoffs for diagnosing pulmonary embolism (PE). OBJECTIVES: We performed a pre/post implementation study, using data from a mid-Atlantic healthcare system comprising 6 hospitals and 400,000 ED visits to determine whether implementing age adjusted D-dimer cutoffs reduced the number of imaging tests performed. METHODS: Retrospective study of all patients who had a D-dimer performed during ED visits between September 2015 to September 2018. On March 21, 2017, the D-dimer upper limit of normal system-wide was increased for patients over 50 to: Age (years) x 0.01µg/mL. D-dimer results were displayed as normal or high based on automated age adjustment. EHR Chart review was performed 1.5 years prior to implementation of age-adjusted D-dimer cutoffs, as well as 1.5 years after to evaluate mortality and test accuracy characteristics such as false negative rates. Comparisons were made using chi-square testing. RESULTS: 22,302 D-dimers were performed pre-implementation of which 10,837 (48.6%) were positive resulting in 7218 (32.3%) imaging studies. After implementation of age-adjusted d-dimer, 25,082 were performed of which 10,851 (43.2%) were positive resulting in 7017 (28.0%) imaging studies. (pre: 48.6%, post: 43.2%; p < 0.01). A significantly lower proportion of patients had a positive d-dimer (pre: 48.6%, post: 43.2%; p < 0.01) and underwent imaging post-implementation (pre: 32.3%, post: 28.0%; p < 0.05) a relative risk reduction of 13.3. This absolute risk reduction of 4.4% is associated with 1104 less scans in the post-implementation group while still increasing test accuracy from 53.7% to 59.2% (p < 0.05). CONCLUSION: Implementation of an automated age-adjusted D-dimer positive reference value reduced CT and V/Q imaging in this population by 4.4% while increasing test accuracy in a regional, heterogeneous six-hospital system.

Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions.

BACKGROUND: Central venous catheter (CVC) complication rates reflecting the application of modern insertion techniques to a clinically heterogeneous patient populations are needed to better understand procedural risk attributable to the 3 common anatomic insertion sites: internal jugular, subclavian, and femoral veins. We sought to define site-specific mechanical and duration-associated CVC complication rates across all hospital inpatients. METHODS: A retrospective chart review was conducted over 9 months at Georgetown University Hospital and Washington Hospital Center. Peripherally inserted central catheters and tunneled or fluoroscopically placed CVC's were excluded. Mechanical complications (retained guidewire, arterial injury, and pneumothorax) and duration-associated complications (deep vein thrombosis or pulmonary embolism, and central line-associated bloodstream infections) were identified. RESULTS: In all, 1179 CVC insertions in 801 adult patients were analyzed. Approximately 32% of patients had multiple lines placed. Of 1179 CVCs, 73 total complications were recorded, giving a total rate of one or more complications occurring per CVC of 5.9%. There was no statistically significant difference between site-specific complications. A total of 19 mechanical complications were documented, with a 1.5% complication rate of one or more mechanical complications occurring. A total of 54 delayed complications were documented, with a 4.4% complication rate of 1 or more delayed complications occurring. There were no statistically significant differences between anatomic sites for either total mechanical or total delayed complications. CONCLUSIONS: These results suggest that site-specific CVC complication rates may be less common than previously reported. These data further inform on the safety of modern CVC insertion techniques across all patient populations and clinical settings.

The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients.

OBJECTIVES: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. DESIGN: Multicenter, prospective cohort study. SETTING: The emergency department and ICUs of 15 medical centers. PATIENTS: Mechanically ventilated adult emergency department patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). CONCLUSIONS: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.

Clinical effects of reported synthetic cannabinoid exposure in patients admitted to the intensive care unit.

OBJECTIVE: To characterize the clinical presentation and hospital course of patients with reported synthetic cannabinoid (SC) exposure requiring Intensive Care Unit (ICU) admission. DESIGN: Retrospective case series of patients admitted to medical or cardiac ICU. SETTING: Urban tertiary care center. PARTICIPANTS: Adults ≥18 years old admitted from the emergency department (ED) in 2015. MEASUREMENTS: Demographics, Sequential Organ Failure Assessment (SOFA) scores, and clinical parameters documenting the effects and hospital course. RESULTS: 23 patients met inclusion criteria. Median age was 47 years (interquartile range [IQR], 32-54); 83% male; 78% black. Patients were generally tachycardic (HR > 100), (65%) and hypertensive (SBP > 140), (65%) on admission. The initial chest X-ray and ECG were abnormal in 43% and 68% of patients, respectively. Pulmonary edema and tachycardia were the most common findings. Head CT imaging was abnormal in 5% of patients. Troponin was elevated >1.0 ng/ml in 3 of 19 patients (16%). Other exposures detected on admission were marijuana (30%), alcohol (30%), and benzodiazepines (26%). The median SOFA score was 6 on admission and decreased over the next 3 days. SOFA scores were primarily driven by altered neurologic status and respiratory failure. 91% required mechanical ventilation, 30% had seizures as a part of presentation, 18% required vasopressors, and 5% needed dialysis. Median hospital and ICU lengths of stay were 2.6 (IQR 1.4-3.5) and 1.6 (IQR 0.9-2.5) days, respectively. The median hospital charge was $37,008. All patients survived the index hospitalization. CONCLUSIONS: Patients admitted to ICU after SC exposure exhibit significant organ dysfunction, particularly neurologic and respiratory. Prognosis is good with supportive care.

Sleep Medicine: Parasomnias.

Parasomnias are abnormal and undesirable behaviors during sleep and are thought to be due to the sleep state instability. Some of them are benign, while some of them point to a possible underlying neurodegenerative process. This article briefly discusses the clinical characteristics, demographics, and pathophysiology of major parasomnias and associated disorders. The classification outlined in this article conforms to the current version of International Classification of Sleep disorders.

The impact of ED crowding on early interventions and mortality in patients with severe sepsis.

OBJECTIVE: Critically ill patients require significant time and care coordination in the emergency department (ED). We hypothesized that ED crowding would delay time to intravenous fluids and antibiotics, decrease utilization of protocolized care, and increase mortality for patients with severe sepsis or septic shock. METHODS: This was a retrospective cohort study of severe sepsis patients admitted to the hospital from the ED between January 2005 and February 2010. Associations between four validated measures of ED crowding (occupancy, waiting patients, admitted patients, and patient-hours) assigned at triage, and time of day, time to antibiotics and fluids, and mortality were tested by analyzing trends across crowding quartiles. RESULTS: During the study period, 2913 severe sepsis patients were admitted to the hospital and 1127 (38.7%) qualified for protocolized care. In-hospital mortality was 14.3% overall and 26% for patients qualifying for protocolized care. Time to IV fluids was delayed as ED occupancy rate increased and as patient hours increased. Time to antibiotics increased as occupancy rates, patient hours, and the number of boarding inpatients increased. Implementation rates of protocolized care decreased from 71.3% to 50.5% (p<0.0001, OR 0.39) as the number of ED inpatient boarders increased; initiation of protocolized care was significantly higher as occupancy increased (OR 1.52). Mortality was unaffected by crowding parameters in all analyses. CONCLUSIONS: With increased ED crowding, time to critical severe sepsis therapies significantly increased and protocolized care initiation decreased. As crowding increases, EDs must implement systems that optimize delivery of time-sensitive therapies to critically ill patients.

Obstructive Sleep Apnea Diagnosis and Management.

The diagnosis and treatment of obstructive sleep apnea is discussed in the context of recent diagnostic and therapeutic advances.

Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED.

OBJECTIVE: There are limited data regarding appropriateness of sedative and paralytic dosing of obese patients undergoing rapid sequence intubation (RSI) in the emergency department. The goal of this study was to compare rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients. METHODS: Retrospective review using a database of endotracheally intubated patients using RSI in an urban, tertiary care academic emergency department, from November 2009 to June 2011. Dosing for succinylcholine and etomidate was calculated as milligrams per kilogram of total body weight (TBW) for each patient, defining appropriate dosing as succinylcholine 1-1.5 mg/kg TBW and etomidate 0.2-0.4 mg/kg TBW. Logistic regression analysis was used to estimate the association between appropriate dosing and World Health Organization body mass index classification. RESULTS: A total of 440 patients were included in the study, 311 (70.7%) classified as nonobese and 129 (29.3%) as obese. two hundred thirty-three (56%) received an inappropriate succinylcholine dose and 107 (24%) received an inappropriate etomidate dose. Obese patients were more likely to be underdosed with succinylcholine (odds ratio [OR], 63.7; 95% confidence interval [CI], 17.8-228.1) and etomidate (OR, 178.3; 95% CI, 37.6-844.7). Nonobese patients were more likely to be overdosed with succinylcholine (OR, 62.5; 95% CI, 17.9-250) and etomidate (OR, 166.7; 95% CI, 37.0-1000). CONCLUSION: Obese patients were more likely to be underdosed during RSI compared with nonobese patients, whereas nonobese patients were more likely to be overdosed with RSI medications. Most obese and nonobese patients were inappropriately dosed with RSI medications, suggesting that physicians are not dosing these medications based on weight.

The relationship between hospital volume and mortality in severe sepsis.

RATIONALE: Severe sepsis is increasing in incidence and has a high rate of inpatient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. OBJECTIVES: We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. METHODS: We performed a retrospective cohort study over a 7-year period (2004-2010), using a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction, and survival. MEASUREMENTS AND MAIN RESULTS: To identify potential differences in outcomes, hospitals were divided into five categories (<50, 50-99, 100-249, 250-499, and 500+ annual cases) and adjusted mortality was compared by volume. A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and inpatient mortality. Hospitals in the highest volume category had substantially improved survival compared with hospitals with the lowest case volume (adjusted odds ratio, 0.64; 95% confidence interval, 0.60-0.69). In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with fewer than 50 annual cases compared with 10.4% in hospitals treating 500+ cases (adjusted odds ratio, 0.54; 95% confidence interval, 0.49-0.59). Similar differences were found in patients with up to three total organ dysfunctions. CONCLUSIONS: Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.

Algid malaria treated with early goal-directed therapy.

Severe malaria complicated by circulatory shock is known as algid malaria. Cases of severe imported malaria are seen increasingly frequently in emergency departments in the United States, Europe, and other locales. The optimal volume resuscitation strategy for patients with severe malaria is not well-defined. A 20-year-old woman, who immigrated 2 weeks ago from Niger, Africa, presented to the emergency department of an urban teaching hospital with fever, hypotension, and malaise. She was resuscitated with 5.5 L of normal saline solution and norepinephrine. Thin blood smear demonstrated Plasmodium falciparum with parasitemia of 10% to 15%. She had rapid reversal of circulatory shock, cleared her parasitemia in less than 48 hours with antimalarial therapy, and was discharged home on hospital day 6 in good condition. The optimal resuscitation strategy for algid malaria is unknown, and volume restriction has been advocated as a means to prevent life-threatening cerebral and pulmonary edema. Although not identical, the late inflammatory response in severe malaria leading to capillary permeability shares many similarities with the immunologic response in bacterial sepsis. Our case report discusses a patient with severe imported malaria complicated by shock, successfully managed with large-volume fluid resuscitation, hemodynamic optimization, early antimalarial agents, and broad-spectrum antibiotics. This report questions the strategy of cautious fluid resuscitation in algid malaria and suggests that case series comparing goal-directed resuscitation to historic controls along with prospective multicenter controlled trials should be conducted to determine the best fluid resuscitation strategy.

Warfarin versus aspirin for prevention of stroke in heart failure: a meta-analysis of randomized controlled clinical trials.

BACKGROUND: There is clinical equipoise between warfarin and aspirin for stroke prevention in patients with heart failure in sinus rhythm (SR). The objective of this meta-analysis was to pool risk estimates for stroke, mortality, and intracerebral hemorrhage (ICH) from published clinical randomized controlled trials (RCTs). METHODS: MEDLINE, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched for English-language RCTs comparing warfarin to aspirin in heart failure through May 2012. Pooled relative risk (RR) was calculated from a random-effects model. RESULTS: Four RCTs (n=3681) met the criteria for study inclusion. Warfarin was associated with a lower risk of stroke compared with aspirin (pooled RR, .59; 95% confidence interval [CI], .41-.85; P=.004). The number needed to treat (NNT) was 61. There was no difference between warfarin and aspirin in mortality (pooled RR, 1; 95% CI, .88-1.13), and ICH (pooled RR, 2.17; 95% CI, .76-6.24). Among secondary outcomes, warfarin was associated with almost twice the risk of major hemorrhage (pooled RR, 1.95; 95% CI, 1.37-2.76; P=.0001) compared with aspirin. The number needed to harm (NNH) was 34. There was no significant difference between warfarin and aspirin in risk of myocardial infarction (MI) (pooled RR, 1.02; 95% CI, .65-1.6], and heart failure exacerbation (HFE) (pooled RR, 1.11; 95% CI, .76-1.63). CONCLUSIONS: Compared with aspirin, warfarin reduced the risk of stroke while conferring an increased risk of major hemorrhage. Warfarin does not increase mortality or confer an increased risk of ICH compared with aspirin.

Impact of COVID-19 Pandemic on Food Insecurity in an Urban Emergency Department Patient Population.

INTRODUCTION: Food insecurity (FI) has been associated with adverse health outcomes and increased healthcare expenditures. Many families experienced reduced access to food during the coronavirus disease 2019 (COVID-19) pandemic. A 2019 study revealed that the pre-pandemic prevalence of FI at an urban, tertiary care hospital's emergency department (ED) was 35.3%. We sought to evaluate whether the prevalence of FI in the same ED patient population increased during the COVID-19 pandemic. METHODS: We performed a single-center, observational, survey-based study. Surveys assessing for FI were administered to clinically stable patients presenting to the ED over 25 consecutive weekdays from November-December 2020. RESULTS: Of 777 eligible patients, 379 (48.8%) were enrolled; 158 (41.7%) screened positive for FI. During the pandemic, there was a 18.1% relative increase (or 6.4% absolute increase) in the prevalence of FI in this population (P=0.040; OR=1.309, 95% CI 1.012-1.693). The majority (52.9%) of food-insecure subjects reported reduced access to food due to the pandemic. The most common perceived barriers to access to food were reduced food availability at grocery stores (31%), social distancing guidelines (26.5%), and reduced income (19.6%). CONCLUSION: Our findings suggest that nearly half of the clinically stable patients who presented to our urban ED during the pandemic experienced food insecurity. The prevalence of FI in our hospital's ED patient population increased by 6.4% during the pandemic. Emergency physicians should be aware of rising FI in their patient population so that they may better support patients who must choose between purchasing food and purchasing prescribed medications.

Isolated hypersomnia due to bilateral thalamic infarcts.

We describe a unique patient who developed hypersomnia as the sole presenting symptom of bilateral thalamic infarcts.

The Survival of the Surviving Sepsis Campaign.

Even well-intentioned policies have great potential to cause harm. This statement is vividly illustrated by the influential, yet controversial, Surviving Sepsis Campaign guidelines and subsequent CMS benchmarks. Despite low-quality evidence, tendentious industry ties, and rebuke from the Infectious Disease Society of America (IDSA), these benchmarks continue to eschew therapy driven by clinician expertise and individual patient needs in favor of mandating an arbitrary, one-size-fits-all approach that suspends clinical judgment and promotes indiscriminate use of treatments that have the potential to cause great harm.

Advanced Triage Protocol: The Role of an Automated Lactate Order in Expediting Rapid Identification of Patients at Risk of Sepsis in the Emergency Department.

We undertook a process improvement initiative to expedite rapid identification of potential sepsis patients based on triage chief complaint, vital signs, and initial lactate level. DESIGN: Prospective cohort study. SETTING: Seven hundred-bed tertiary care hospital with ≅65,000 patient visits/yr. PATIENTS: Patients presenting to emergency department (ED) triage who met the following criteria: greater than or equal to two of the three systemic inflammatory response syndrome criteria assessable in triage, a chief complaint suggestive of infection, emergency severity index 2 or 3, and ambulatory to ED. INTERVENTIONS: A computer-generated lactate order was created, staff education and resources increased, and point-of-care lactate testing was introduced. MEASUREMENTS AND MAIN RESULTS: Primary endpoints include the following: percent of patients having a lactate level drawn, percent of lactate samples resulting before room placement, and time intervals from triage to lactate blood draw and to lactate result. Secondary endpoints were percentage of patients admitted to the hospital, percentage admitted to the ICU, and in-hospital mortality. Six thousand nine hundred six patients were included: 226 historic controls (HCs) and 6,680 intervention group patients. The mean serum lactate level was 1.77 ± 1.18 mmol/L. The percentage of patients having a lactate resulted increased from 27.4% in the HC period to 79.6%. The percentage of these lactate results available while the patient was still in the waiting room increased from 0.4% during the HC period to 33.7% during Phase 5 (p < 0.0001). In the intervention period, time from triage to lactate result decreased (78.1-63.4 min; p < 0.0001) and time to treatment room decreased (59.3-39.6 min; p < 0.0001). CONCLUSIONS: Implementation of a computerized lactate order using readily available data obtained during ED triage, combined with point-of-care lactate testing, improves time to lactate blood draw and lactate result in patients at risk for severe sepsis. Initial lactate levels correlated with admission to the hospital, admission to the ICU, and in-hospital mortality.

Development and Validation of a Two-Step Predictive Risk Stratification Model for Coronavirus Disease 2019 In-hospital Mortality: A Multicenter Retrospective Cohort Study.

Objectives: An accurate prognostic score to predict mortality for adults with COVID-19 infection is needed to understand who would benefit most from hospitalizations and more intensive support and care. We aimed to develop and validate a two-step score system for patient triage, and to identify patients at a relatively low level of mortality risk using easy-to-collect individual information. Design: Multicenter retrospective observational cohort study. Setting: Four health centers from Virginia Commonwealth University, Georgetown University, the University of Florida, and the University of California, Los Angeles. Patients: Coronavirus Disease 2019-confirmed and hospitalized adult patients. Measurements and Main Results: We included 1,673 participants from Virginia Commonwealth University (VCU) as the derivation cohort. Risk factors for in-hospital death were identified using a multivariable logistic model with variable selection procedures after repeated missing data imputation. A two-step risk score was developed to identify patients at lower, moderate, and higher mortality risk. The first step selected increasing age, more than one pre-existing comorbidities, heart rate >100 beats/min, respiratory rate ≥30 breaths/min, and SpO2 <93% into the predictive model. Besides age and SpO2, the second step used blood urea nitrogen, absolute neutrophil count, C-reactive protein, platelet count, and neutrophil-to-lymphocyte ratio as predictors. C-statistics reflected very good discrimination with internal validation at VCU (0.83, 95% CI 0.79-0.88) and external validation at the other three health systems (range, 0.79-0.85). A one-step model was also derived for comparison. Overall, the two-step risk score had better performance than the one-step score. Conclusions: The two-step scoring system used widely available, point-of-care data for triage of COVID-19 patients and is a potentially time- and cost-saving tool in practice.