A randomized controlled trial comparing efficacy of early video capsule endoscopy with standard of care in the approach to nonhematemesis GI bleeding (with videos).

BACKGROUND AND AIMS: Patients presenting with nonhematemesis GI bleeding (NHGIB) represent a diagnostic challenge for physicians. We performed a randomized controlled trial to assess the benefits of deployment of a video capsule soon after admission in the management of patients presenting with melena, hematochezia, or severe anemia compared with standard of care management. METHODS: Patients admitted with NHGIB were randomized and placed into 1 of 2 study groups. In the experimental group, patients ingested a video capsule soon after admission to the hospital. These patients had further endoscopic workup based on the findings from the capsule. Patients in the control group underwent endoscopic evaluation (ie, upper endoscopy, capsule endoscopy, and/or colonoscopy) to identify the source of bleeding as directed by the attending gastroenterologist's interpretation of their clinical presentation. The primary endpoint for this study was the rate of localization of bleeding during hospitalization. RESULTS: Eighty-seven patients were included in this study: 45 randomized to the standard of care arm and 42 to the early capsule arm. A bleeding source was localized in 64.3% of the patients in the early capsule arm and in 31.1% of the patients in the standard of care arm (P < .01). The likelihood of endoscopic localization of bleeding over time was greater for patients receiving early capsule endoscopy compared with those in the standard of care arm (adjusted hazard ratio, 2.77; 95% confidence interval, 1.36-5.64). CONCLUSIONS: For patients admitted to the hospital for NHGIB, early capsule endoscopy is a safe and effective alternative for the detection of the source of bleeding. (Clinical trial registration number: NCT02442830.).

Reduction in STEMI transfer times utilizing a municipal "911" ambulance service.

INTRODUCTION: The time interval from diagnosis to reperfusion therapy for patients experiencing ST-segment elevation myocardial infarction (STEMI) has a significant impact on morbidity and mortality. HYPOTHESIS: It is hypothesized that the time required for interfacility patient transfers from a community hospital to a regional percutaneous coronary intervention (PCI) center using an Advanced Life Support (ALS) transfer ambulance service is no different than utilizing the "911" ALS ambulance. METHODS: Quality assurance data collected by a tertiary care center cardiac catheterization program were reviewed retrospectively. Data were collected on all patients with STEMI requiring interfacility transfer from a local community hospital to the tertiary care center's PCI suite, approximately 16 miles away by ground, 12 miles by air. In 2009, transfers of patients with STEMI were redirected to the municipal ALS ambulance service, instead of the hospital's contracted ALS transfer service. Data were collected from January 2007 through May 2013. Temporal data were compared between transports initiated through the contracted ALS ambulance service and the municipal ALS service. Data points included time of initial transport request and time of ambulance arrival to the sending facility and the receiving PCI suite. RESULTS: During the 4-year study period, 63 patients diagnosed with STEMI and transferred to the receiving hospital's PCI suite were included in this study. Mean times from the transport request to arrival of the ambulance at the sending hospital's emergency department were six minutes (95% CI, 4-7 minutes) via municipal ALS and 13 minutes (95% CI, 9-16 minutes) for the ALS transfer service. The mean times from the ground transport request to arrival at the receiving hospital's PCI suite when utilizing the municipal ALS ambulance and hospital contracted ALS ambulance services were 48 minutes (95% CI, 33-64 minutes) and 56 minutes (95% CI 52-59 minutes), respectively. This eight-minute period represented a 14% (P = .001) reduction in the mean transfer time to the PCI suite for patients transported via the municipal ALS ambulance. CONCLUSION: In the appropriate setting, the use of the municipal "911" ALS ambulance service for the interfacility transport of patients with STEMI appears advantageous in reducing door-to-catheterization times.

Prehospital Intubations Are Associated with Elevated Endotracheal Tube Cuff Pressures: A Cross-Sectional Study Characterizing ETT Cuff Pressures at a Tertiary Care Emergency Department.

INTRODUCTION: Emergency Medical Services (EMS) providers are trained to place endotracheal tubes (ETTs) in the prehospital setting when indicated. Endotracheal tube cuffs are traditionally inflated with 10cc of air to provide adequate seal against the tracheal lumen. There is literature suggesting that many ETTs are inflated well beyond the accepted safe pressures of 20-30cmH2O, leading to potential complications including ischemia, necrosis, scarring, and stenosis of the tracheal wall. Currently, EMS providers do not routinely check ETT cuff pressures. It was hypothesized that the average ETT cuff pressure of patients arriving at the study site who were intubated by EMS exceeds the safe pressure range of 20-30cmH2O. OBJECTIVES: While ETT cuff inflation is necessary to close the respiratory system, thus preventing air leaks and aspiration, there is evidence to suggest that over-inflated ETT cuffs can cause long-term complications. The purpose of this study is to characterize the cuff pressures of ETTs placed by EMS providers. METHODS: This project was a single center, prospective observational study. Endotracheal tube cuff pressures were measured and recorded for adult patients intubated by EMS providers prior to arrival at a large, urban, tertiary care center over a nine-month period. All data were collected by respiratory therapists utilizing a cuff pressure measurement device which had a detectable range of 0-100cmH2O and was designed as a syringe. Results including basic patient demographics, cuff pressure, tube size, and EMS service were recorded. RESULTS: In total, 45 measurements from six EMS services were included with ETT sizes ranging from 6.5-8.0mm. Mean patient age was 52.2 years (67.7% male). Mean cuff pressure was 81.8cmH2O with a range of 15 to 100 and a median of 100. The mode was 100cmH2O; 40 out of 45 (88.9%) cuff pressures were above 30cmH2O. Linear regression showed no correlation between age and ETT cuff pressure or between ETT size and cuff pressure. Two-tailed T tests did not show a significant difference in the mean cuff pressure between female versus male patients. CONCLUSION: An overwhelming majority of prehospital intubations are associated with elevated cuff pressures, and cuff pressure monitoring education is indicated to address this phenomenon.

An Unusual Case Report of COVID-19 Presenting with Meningitis Symptoms and Shingles.

INTRODUCTION: As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads across the globe, physicians face the challenges of a contagious pandemic including which patients to isolate, how to conserve personal protective equipment, and who to test. The current protocol at our hospital is to place anyone with new cough, dyspnea, or fever into airborne and contact precautions and consider them for testing. Unfortunately, the symptomatic presentations of coronavirus disease 2019 (COVID-19) are proving more variable than previously thought. CASE REPORT: Our case of COVID-19 presented with headache and then progressed to a meningitis-like illness with co-existing shingles rash. CONCLUSION: COVID-19 can have a variety of initial presentations that are not the classic respiratory symptoms and fever. These presenting symptoms of COVID-19 can include a meningitis-like illness, as our case report indicates. The wide variety of presentations of COVID-19 may warrant widespread testing to identify cases, protect healthcare workers, and prevent the spread of this pandemic.

Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls.

INTRODUCTION: Although emergency medical services (EMS) standing-order protocols provide more efficient and accurate on-scene management by paramedics, online medical direction (OLMD) has not been eliminated from practice. In this modern era of OLMD, no studies exist to describe the prevalence of reasons for contacting OLMD. OBJECTIVES: The primary goal of this study was to describe the quantity of and reasons for calls for medical direction. We also sought to determine time diverted from emergency physicians due to OLMD. Finally, we hoped to identify any areas for potential improvement or additional training opportunities for EMS providers. METHODS: This was a descriptive study with retrospective data analysis of recorded OLMD calls from January 1, 2016, to December 31, 2016. Data were extracted by research personnel listening to audio recordings and were entered into a database for descriptive analysis. We abstracted the date and length of call, patient demographic information (age and gender), category of call (trauma, medical, cardiac, or obstetrics), reason for call, and origin of call (prehospital, interhospital, nursing home, or discharge). RESULTS: The total number of recordings analyzed was 519. Calls were divided into four categories pertaining to their nature: 353 (68.5%) medical; 70 (13.6%) trauma; 83 (16.1%) cardiac; and 9 (8%) were obstetrics related. Repeat calls regarding the same patient encounter comprised 48 (9.4%) of the calls. Patient refusal of transport was the most common reason for a call medical direction (32.3% of calls). The total time for medical direction calls for the year was 26.6 hours. The maximum number of calls in a single day was seven, with a mean of 2.04 calls per day (standard deviation [SD] ± 1.18). The mean call length was 3.06 minutes (SD ± 2.51). CONCLUSION: Our analysis shows that the use of OLMD frequently involves complex decision-making such as determination of the medical decision-making capacity of patients to refuse treatment and transport, and evaluation of the appropriate level of care for interfacility transfers. Further investigation into the effect of EMS physician-driven medical direction on both the quality and time required for OLMD could allow for better identification of areas of potential improvement and training.

Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination.

OBJECTIVES: If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments. METHODS: This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p-values comparing the proportion in each cohort that responded "no capacity." Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts. RESULTS: The inter-rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded "no capacity" was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians). CONCLUSIONS: There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services.

INTRODUCTION: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified-those arriving by private vehicle. METHODS: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors. RESULTS: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27-0.96) for achieving DTA ≤ 15 minutes. CONCLUSION: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.

Retrospective Analysis of Mosh-Pit-Related Injuries.

OBJECTIVES: Moshing is a violent form of dancing found world-wide at rock concerts, festivals, and electronic dance music events. It involves crowd surfing, shoving, and moving in a circular rotation. Moshing is a source of increased morbidity and mortality. The goal of this study was to report epidemiologic information on patient presentation rate (PPR), transport to hospital rate (TTHR), and injury patterns from patients who participated in mosh-pits. Materials and Methods Subjects were patrons from mosh-pits seeking medical care at a single venue. The events reviewed were two national concert tours which visited this venue during their tour. The eight distinct events studied occurred between 2011 and 2014. Data were collected retrospectively from prehospital patient care reports (PCRs). A single Emergency Medical Service (EMS) provided medical care at this venue. The following information was gathered from each PCR: type of injury, location of injury, treatment received, alcohol or drug use, Advanced Life Support/ALS interventions required, age and gender, disposition, minor or parent issues, as well as type of activity engaged in when injured. RESULTS: Attendance for the eight events ranged from 5,100 to 16,000. Total patient presentations ranged from 50 to 206 per event. Patient presentations per ten thousand (PPTT) ranged from 56 to 130. The TTHR per 10,000 ranged from seven to 20. The mean PPTT was 99 (95% CI, 77-122) and the median was 98. The mean TTHR was 16 (95% CI, 12-29) and the median TTHR was 17. Patients presenting from mosh-pits were more frequently male (57.6%; P<.004). The mean age was 20 (95% CI, 19-20). Treatment received was overwhelmingly at the Basic Life Support (BLS) level (96.8%; P<.000001). General moshing was the most common activity leading to injury. Crowd surfing was the next most significant, accounting for 20% of presentations. The most common body part injured was the head (64% of injuries). CONCLUSIONS: This retrospective review of mosh-pit-associated injury patterns demonstrates a high rate of injuries and presentations for medical aid at the evaluated events. General moshing was the most commonly associated activity and the head was the most common body part injured. Milsten AM , Tennyson J , Weisberg S , Retrospective analysis of mosh-pit-related injuries. Prehosp Disaster Med. 2017;32(6):636-641.

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS.

INTRODUCTION: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea.1, 2,3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. METHODS: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. RESULTS: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH2O. Maximum altitude for the program ranged from 1,000-3,000 feet above sea level, with a change in altitude from 800-2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. CONCLUSION: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs.

Thoracic Spine Fracture in a Survivor of Out-of-Hospital Cardiac Arrest with Mechanical CPR.

This is a report of a thoracic vertebral fracture in a 79-year-old male survivor of out-of-hospital cardiac arrest with chest compressions provided by a LUCAS 2 (Physio-Control Inc.; Lund Sweden) device. This is the first such report in the literature of a vertebral fracture being noted in a survivor of cardiac arrest where an automated compression device was used. Marshall RT , Kotecha H , Chiba T , Tennyson J . Thoracic spine fracture in a survivor of out-of-hospital cardiac arrest with mechanical CPR. Prehosp Disaster Med. 2016;31(6):684-686.

Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Helicopter EMS Transport.

INTRODUCTION: Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. METHODS: We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. RESULTS: We analyzed data for 55 patients. There was a mean age of 57 years (range 18-90). The mean ETT cuff pressure was 70 (95% CI= [61-80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. CONCLUSION: Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should use ETT cuff manometry to ensure that they inflate ETT cuffs to safe pressures.

Knowledge and Beliefs of EMS Providers toward Lights and Siren Transportation.

INTRODUCTION: The use of warning lights and siren (WLS) increases the risk of ambulance collisions. Multiple studies have failed to demonstrate a clinical benefit to the patients. We sought to investigate the degree to which providers understand the data and incorporate it into their practice. METHODS: The authors distributed an anonymous survey to prehospital providers under their medical direction at staff and quality assurance meetings. The surveys asked the providers' degree of agreement with four statements: transport with lights and siren shortens transport times; transport with lights and siren improves patient outcome; transport with lights and siren increases the risk of collision during transport; and transport with lights and siren reduces the utilization of "mutual aid" service. We compared responses between providers who had been in prior ambulance collisions and those who had not. RESULTS: Few responses reached statistical significance, but respondents tended towards agreement that WLS use shortens transport times, that it does not improve outcomes, and that it increases the risk of collision. Despite the overall agreement with the published literature, respondents report >80% of transports are conducted using WLS. CONCLUSION: The data demonstrate the surveyed providers are aware of the risk posed by WLS to themselves, their patients, and the public. Nevertheless, their practice in the absence of rigid protocols suggests they disregard this knowledge. Despite a large number of prior ambulance collisions among the surveyed group, a high number of transports are conducted using WLS.

Diversion of buprenorphine/naloxone coformulated tablets in a region with high prescribing prevalence.

The purpose of this article was to characterize practices of buprenorphine/naloxone (B/N) diversion in a region with a high prescribing prevalence. A cross-sectional, open-ended survey was administered to individuals entering opioid addiction treatment programs in two New England states. The authors obtained formative information about the knowledge, attitudes, beliefs, practices, and street economy of B/N diversion. The authors interviewed 51 individuals, 49 of which were aware of B/N medication. Of that number, 100% had diverted B/N to modulate opiate withdrawal symptoms arising from attempted "self-detoxification," insufficient funds to purchase preferred illicit opioids, or inability to find a preferred source of drugs. Thirty of 49 (61%) participants obtained the illicit drug from an individual holding a legitimate prescription for B/N. A high proportion of individuals in the study locations who sought treatment for opioid addiction self-reported the purchase and use of diverted B/N. The diversion of B/N may be minimized by modifying educational, treatment, monitoring, and dispensing practices.