Developing a National Trauma Research Action Plan: Results from the Neurotrauma Research Panel Delphi Survey.

BACKGROUND: In 2016, the National Academies of Science, Engineering and Medicine called for the development of a National Trauma Research Action Plan. The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. Given the public health burden of injuries to the central nervous system, neurotrauma was one of 11 panels formed to address this recommendation with a gap analysis and generation of high-priority research questions. METHODS: We recruited interdisciplinary experts to identify gaps in the neurotrauma literature, generate research questions, and prioritize those questions using a consensus-driven Delphi survey approach. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the importance of the questions on a 9-point Likert scale. Consensus was defined as 60% or greater of panelists agreeing on the priority category. We then coded research questions using an National Trauma Research Action Plan taxonomy of 118 research concepts, which were consistent across all 11 panels. RESULTS: Twenty-eight neurotrauma experts generated 675 research questions. Of these, 364 (53.9%) reached consensus, and 56 were determined to be high priority (15.4%), 303 were deemed to be medium priority (83.2%), and 5 were low priority (1.4%). The research topics were stratified into three groups-severe traumatic brain injury (TBI), mild TBI (mTBI), and spinal cord injury. The number of high-priority questions for each subtopic was 46 for severe TBI (19.7%), 3 for mTBI (4.3%) and 7 for SCI (11.7%). CONCLUSION: This Delphi gap analysis of neurotrauma research identified 56 high-priority research questions. There are clear areas of focus for severe TBI, mTBI, and spinal cord injury that will help guide investigators in future neurotrauma research. Funding agencies should consider these gaps when they prioritize future research. LEVEL OF EVIDENCE: Diagnostic Test or Criteria, Level IV.

Translating COVID-19 knowledge to practice: Enhancing emergency medicine using the "wisdom of crowds".

In the spring of 2020, emergency physicians found themselves in new, uncharted territory as there were few data available for understanding coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. In response, knowledge was being crowd sourced and shared across online platforms. The "wisdom of crowds" is an important vehicle for sharing information and expertise. In this article, we explore concepts related to the social psychology of group decisionmaking and knowledge translation. We then analyze a scenario in which the American College of Emergency Physicians (ACEP), a professional medical society, used the wisdom of crowds (via the EngagED platform) to disseminate clinically relevant information and create a useful resource called the "ACEP COVID-19 Field Guide." We also evaluate the crowd-sourced approach, content, and attributes of EngagED compared to other social media platforms. We conclude that professional organizations can play a more prominent role using the wisdom of crowds for augmenting pandemic response efforts.

Human metapneumovirus: an emerging respiratory pathogen.

Human metapneumovirus (hMPV) is an important emerging respiratory pathogen, previously unreported in the Emergency Medicine literature. It is primarily associated with the clinical syndromes of bronchiolitis and pneumonia. hMPV may predispose to bacterial pneumonia; coinfection with respiratory syncytial virus may lead to increased severity of clinical disease, and complications include asthma and chronic obstructive pulmonary disease exacerbations. Given its high prevalence and potential clinical implications as these patients present to the Emergency Department with initial infection or subsequent complications, a better understanding of hMPV will aid in their care. We report the case of a 13-month old who developed lobar pneumonia 3 weeks after being diagnosed with hMPV. The epidemiology, clinical presentation, complications, and treatment of hMPV are then discussed.

Evaluation of time required for water-only decontamination of an oil-based agent.

STUDY OBJECTIVE: The objective was to evaluate the time to decontaminate an area of skin exposed to an oil-based agent using a water-only decontamination protocol. METHODS: A fluorescent mock chemical/biological agent was created. Each of 20 subjects had his/her forearm sprayed with the agent. Each subject placed his/her arm under a decontamination shower, which provided water at a pressure of 60-70 psi and 35 degrees C. After 30 sec a black light was used by three evaluators to determine whether the agent was removed. The process of 30 sec decontamination and re-evaluation was repeated for a total of 5 min. The primary endpoint was proportion decontaminated over time. RESULTS: After 90 sec, 100% of subjects were decontaminated. CONCLUSION: Whereas the data suggest the possibility of rapid water-only decontamination, the applicability of this data in current form is doubtful, but provides a model as a basis for future study.

Utility of Nonspecific Laboratory Testing for Psychiatric Patients Undergoing Medical Screening in a Military Emergency Department.

INTRODUCTION: Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs. MATERIALS AND METHODS: A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms. RESULTS: Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses. CONCLUSIONS: The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.

COVID-19 in Seattle-Early lessons learned.

The coronavirus disease 2019 (COVID-19) pandemic has rapidly evolved and now dominates the attention and full efforts of the emergency medicine community, both domestic and abroad. Seattle is the site of the initial diagnosed COVID-19 cases and fatalities in the United States. We provide an overview of the system-level response of 6 Seattle emergency departments and the Washington state chapter of the American College of Emergency Physicians (ACEP) to the COVID-19 pandemic. Local efforts involved the spectrum of emergency response including on- and off-site triage strategies, an approach to personal protective equipment, testing and reporting protocols, early treatments, communication strategies, the impact on front-line providers, and ongoing work.

Principles of basic wound evaluation and management in the emergency department.

The primary objectives of basic wound management center around promoting optimal wound healing and cosmesis. These objectives may be achieved through the systematic assessment, preparation, and repair of the laceration supplemented with appropriate patient care instructions. The meticulous and methodical management of traumatic wounds described in this article will assist the emergency physician in decreasing overall complication rates and help improve patient satisfaction.

Security, Violent Events, and Anticipated Surge Capabilities of Emergency Departments in Washington State.

INTRODUCTION: Over the past 15 years, violent threats and acts against hospital patients, staff, and providers have increased and escalated. The leading area for violence is the emergency department (ED) given its 24/7 operations, role in patient care, admissions gateway, and center for influxes during acute surge events. This investigation had three objectives: to assess the current security of Washington State EDs; to estimate the prevalence of and response to threats and violence in Washington State EDs; and to appraise the Washington State ED security capability to respond to acute influxes of patients, bystanders, and media during acute surge events. METHODS: A voluntary, blinded, 28-question Web-based survey developed by emergency physicians was electronically delivered to all 87 Washington State ED directors in January 2013. We evaluated responses by descriptive statistical analyses. RESULTS: Analyses occurred after 90% (78/87) of ED directors responded. Annual censuses of the EDs ranged from < 20,000 to 100,000 patients and represented the entire spectrum of practice environments, including critical access hospitals and a regional quaternary referral medical center. Thirty-four of 75 (45%) reported the current level of security was inadequate, based on the general consensus of their ED staff. Nearly two-thirds (63%) of EDs had 24-hour security personnel coverage, while 28% reported no assigned security personnel. Security personnel training was provided by 45% of hospitals or healthcare systems. Sixty-nine of 78 (88%) respondents witnessed or heard about violent threats or acts occurring in their ED. Of these, 93% were directed towards nursing staff, 90% towards physicians, 74% towards security personnel, and 51% towards administrative personnel. Nearly half (48%) noted incidents directed towards another patient, and 50% towards a patient's family or friend. These events were variably reported to the hospital administration. After an acute surge event, 35% believed the initial additional security response would not be adequate, with 26% reporting no additional security would be available within 15 minutes. CONCLUSION: Our study reveals the variability of ED security staffing and a heterogeneity of capabilities throughout Washington State. These deficiencies and vulnerabilities highlight the need for other EDs and regional emergency preparedness planners to conduct their own readiness assessments.

Intravenous Ondansetron and the QT Interval in Adult Emergency Department Patients: An Observational Study.

OBJECTIVES: Ondansetron is known to cause QT interval prolongation, but this effect and clinical significance has not been prospectively studied in adult emergency department (ED) patients. The primary objective was to determine the mean maximal corrected QT interval (QTc) prolongation after intravenous (IV) administration of 4 mg of ondansetron. The secondary objective was to report any serious adverse cardiac electrical events. METHODS: This was a prospective, observational, single-center cohort study conducted between 2012 and 2013 in an academic, military hospital ED. Adult patients ordered to receive 4 mg of IV ondansetron were eligible for the study. A six-lead electrocardiogram was recorded at baseline and every 2 minutes after ondansetron administration for 20 minutes. The QTc was calculated using the Bazett formula. Serious adverse cardiac electrical events (nonsinus rhythm, severe bradycardia, and sudden cardiac death) were also recorded. RESULTS: Twenty-two adult ED patients were enrolled. Ondansetron caused a mean prolongation of the QTc by 20 ms (95% confidence interval [CI] = 14 to 26 ms), with a mean proportion change from baseline of 5.2% (95% CI = 3.8% to 6.6%). There were zero (95% CI = 0 to 13%) reported serious adverse cardiac electrical events. CONCLUSIONS: While QTc prolongation does occur in adult ED patients receiving IV ondansetron, the clinical impact is questionable.

Bradycardia-associated torsade de pointes and the long-QT syndromes: a case report and review of the literature.

We report a case of bradycardia-associated torsade de pointes in which the underlying long-QT syndrome appeared to be attributable to primary cardiac conducting system disease. Our patient presented complaining of presyncope and syncope. Serial electrocardiograms obtained over a period of 10 years demonstrated slowly progressive conduction system abnormalities, and evaluation revealed no other cause. The patient's dysrhythmia was refractory to magnesium but abated with cardiac pacing at a moderate rate. A review of the relevant literature on congenital and acquired long-QT syndrome is included.

SARS and its impact on current and future Emergency Department operations.

A long-standing concern for international spread of new, virulent pathogens became a reality with the advent of Severe Acute Respiratory Syndrome (SARS). This respiratory syndrome, caused by a coronavirus, spread rapidly across 30 nations since its first recognition in late 2002. SARS has presented the greatest recent threat to U.S. public health, and has come at a time when purposeful introduction of pathogens by terrorists is also of heightened concern. SARS has forced the international medical establishment to reexamine how best to manage such incidents.

Emergency department management of delirium in the elderly.

An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.