External evaluation of Brain Injury Guideline (BIG) low risk criteria for traumatic brain injury.

BACKGROUND: Fewer than 20 % of traumatic brain injury (TBI) cases with traumatic intracranial hemorrhage (ICH) result in clinical deterioration. The Brain Injury Guideline (BIG) criteria were published in 2014 and categorize patients with TBI into three risk groups (BIG 1, 2, and 3) based on CT scan findings, neurological examination, anti-coagulant/platelet medications, and intoxication. Early data is promising, suggesting no instances of neurosurgical intervention or death in the low-risk BIG1 category within 30 days. We sought to externally validate the BIG criteria and identify patients with TBI at low risk of clinical deterioration. We hypothesized that patients meeting the BIG1 low risk criteria have less than a 1 % risk of death or neurosurgical intervention. METHODS: We performed a retrospective cohort study of a level 1 trauma center's trauma registry records from 2011 to 2022 to identify patients with head trauma. We abstracted demographics, injury characteristics, clinical course, CT imaging results, and outcomes, and we categorized patients according to the BIG criteria. The Clopper-Pearson Exact method was used to estimate outcome frequency with confidence intervals. The primary outcome was death or neurosurgical intervention within 30 days. Secondary outcomes included progression on repeat head CT (RHCT), ICU admission with neurocritical care intervention, and TBI-related hospital readmission within 30 days. RESULTS: A total of 1714 patients with TBI with ICH were identified from the trauma registry. 325 patients were excluded due to missing data, pregnancy, incarceration, polytrauma, or GCS < 13, leaving 1389 for analysis. 193 patients (13.9 %) were classified as BIG1. No patients classified as BIG1 experienced the primary outcome measures of death or neurosurgical intervention (95 % confidence interval [CI]: 0 %-1.9 %). The number of patients who experienced the secondary outcome measures of progression on RHCT, ICU admission with neurocritical care intervention, or TBI-related hospital readmission within 30 days were 9 (4.7 %, 95 % CI: 2.2 %-8.7 %), 1 (0.5 %, 95 % CI: 0 %-2.9 %), and 4 (2.1 %, 95 % CI: 0.6 %-5.2 %), respectively. CONCLUSION: BIG1 criteria identified a low-risk subset of patients with TBI with ICH. However, an upper 95 % CI of 1.9 % does not exclude the risk of neurologic deterioration being <1 %. Validation of these criteria in larger cohorts is warranted.

Real-Time Electronic Patient Portal Use Among Emergency Department Patients.

Importance: Patients with inequitable access to patient portals frequently present to emergency departments (EDs) for care. Little is known about portal use patterns among ED patients. Objectives: To describe real-time patient portal usage trends among ED patients and compare demographic and clinical characteristics between portal users and nonusers. Design, Setting, and Participants: In this cross-sectional study of 12 teaching and 24 academic-affiliated EDs from 8 health systems in California, Connecticut, Massachusetts, Ohio, Tennessee, Texas, and Washington, patient portal access and usage data were evaluated for all ED patients 18 years or older between April 5, 2021, and April 4, 2022. Exposure: Use of the patient portal during ED visit. Main Outcomes and Measures: The primary outcomes were the weekly proportions of ED patients who logged into the portal, viewed test results, and viewed clinical notes in real time. Pooled random-effects models were used to evaluate temporal trends and demographic and clinical characteristics associated with real-time portal use. Results: The study included 1 280 924 unique patient encounters (53.5% female; 0.6% American Indian or Alaska Native, 3.7% Asian, 18.0% Black, 10.7% Hispanic, 0.4% Native Hawaiian or Pacific Islander, 66.5% White, 10.0% other race, and 4.0% with missing race or ethnicity; 91.2% English-speaking patients; mean [SD] age, 51.9 [19.2] years). During the study, 17.4% of patients logged into the portal while in the ED, whereas 14.1% viewed test results and 2.5% viewed clinical notes. The odds of accessing the portal (odds ratio [OR], 1.36; 95% CI, 1.19-1.56), viewing test results (OR, 1.63; 95% CI, 1.30-2.04), and viewing clinical notes (OR, 1.60; 95% CI, 1.19-2.15) were higher at the end of the study vs the beginning. Patients with active portal accounts at ED arrival had a higher odds of logging into the portal (OR, 17.73; 95% CI, 9.37-33.56), viewing test results (OR, 18.50; 95% CI, 9.62-35.57), and viewing clinical notes (OR, 18.40; 95% CI, 10.31-32.86). Patients who were male, Black, or without commercial insurance had lower odds of logging into the portal, viewing results, and viewing clinical notes. Conclusions and Relevance: These findings suggest that real-time patient portal use during ED encounters has increased over time, but disparities exist in portal access that mirror trends in portal usage more generally. Given emergency medicine's role in caring for medically underserved patients, there are opportunities for EDs to enroll and train patients in using patient portals to promote engagement during and after their visits.

Program director longevity in emergency medicine residencies: A 40-year analysis.

Objective: We sought to assess trends in emergency medicine residency program director (PD) length of service over the past 40 years and evaluate relationships between duration of service and important factors such as PD start year, geographic region, and year of program initial accreditation. Methods: We retrospectively analyzed program data from the American Medical Association Graduate Medical Education Directory and Emergency Medicine Residents' Association Match database. We calculated descriptive statistics and used linear regression to assess the impact of PD start year, region, and year of program initial accreditation on PD duration of service. Results: We gathered data on 783 unique PDs between 1983 and 2023. The overall mean ± SD PD duration of service was 6.19 ± 4.72 years (range 1-29 years). The mean duration of service by decade of start date was 6.49 years in the 1980s, 7.39 years in the 1990s, 5.92 years in the 2000s, 4.08 years in the 2010s, and 2 years in the 2020s. Both PD start year (p = 0.002) and program initial accreditation year (p = 0.001) significantly predicted duration of PD service. Region did not significantly predict duration of PD service (p = 0.225). Conclusions: Duration of service as a PD is decreasing in recent decades. Both PD start year and year of initial program accreditation significantly predict duration of service as PD. Future research must be done to better understand this phenomenon and uncover strategies to promote PD longevity.

Metabolic Manipulation and Therapeutic Hypothermia.

Hypothermia has multiple physiological effects, including decreasing metabolic rate and oxygen consumption (VO2). There are few human data about the magnitude of change in VO2 with decreases in core temperature. We aimed to quantify to magnitude of reduction in resting VO2 as we reduced core temperature in lightly sedated healthy individuals. After informed consent and physical screening, we cooled participants by rapidly infusing 20 mL/kg of cold (4°C) saline intravenously and placing surface cooling pads on the torso. We attempted to suppress shivering using a 1 mcg/kg intravenous bolus of dexmedetomidine followed by titrated infusion at 1.0 to 1.5 µg/(kg·h). We measured resting metabolic rate VO2 through indirect calorimetry at baseline (37°C) and at 36°C, 35°C, 34°C, and 33°C. Nine participants had mean age 30 (standard deviation 10) years and 7 (78%) were male. Baseline VO2 was 3.36 mL/(kg·min) (interquartile range 2.98-3.76) mL/(kg·min). VO2 was associated with core temperature and declined with each degree decrease in core temperature, unless shivering occurred. Over the entire range from 37°C to 33°C, median VO2 declined 0.7 mL/(kg·min) (20.8%) in the absence of shivering. The largest average decrease in VO2 per degree Celsius was by 0.46 mL/(kg·min) (13.7%) and occurred between 37°C and 36°C in the absence of shivering. After a participant developed shivering, core body temperature did not decrease further, and VO2 increased. In lightly sedated humans, metabolic rate decreases around 5.2% for each 1°C decrease in core temperature from 37°C to 33°C. Because the largest decrease in metabolic rate occurs between 37°C and 36°C, subclinical shivering or other homeostatic reflexes may be present at lower temperatures.

Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest.

BACKGROUND: While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival. METHODS: We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission. RESULTS: We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival. CONCLUSIONS: Depression is an independent risk factor for hospital readmission in CA survivors.

Diagnostic yield of computed tomography after non-traumatic out-of-hospital cardiac arrest.

AIM: Determine the frequency with which computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) identifies clinically important findings. METHODS: We included non-traumatic OHCA patients treated at a single center from February 2019 to February 2021. Clinical practice was to obtain CT head in comatose patients. Additionally, CT of the cervical spine, chest, abdomen, and pelvis were obtained if clinically indicated. We identified CT imaging obtained within 24 hours of emergency department (ED) arrival and summarized radiology findings. We used descriptive statistics to summarize population characteristics and imaging results, report their frequencies and, post hoc, compared time from ED arrival to catheterization between patients who did and did not undergo CT. RESULTS: We included 597 subjects, of which 491 (82.2%) had a CT obtained. Time to CT was 4.1 hours [2.8-5.7]. Most (n = 480, 80.4%) underwent CT head, of which 36 (7.5%) had intracranial hemorrhage and 161 (33.5%) had cerebral edema. Fewer subjects (230, 38.5%) underwent a cervical spine CT, and 4 (1.7%) had acute vertebral fractures. Most subjects (410, 68.7%) underwent a chest CT, and abdomen and pelvis CT (363, 60.8%). Chest CT abnormalities included rib or sternal fractures (227, 55.4%), pneumothorax (27, 6.6%), aspiration or pneumonia (309, 75.4%), mediastinal hematoma (18, 4.4%) and pulmonary embolism (6, 3.7%). Significant abdomen and pelvis findings were bowel ischemia (24, 6.6%) and solid organ laceration (7, 1.9%). Most subjects that had CT imaging deferred were awake and had shorter time to catheterization. CONCLUSIONS: CT identifies clinically important pathology after OHCA.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia.

Objective: Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. Materials and methods: We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Results: Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). Conclusion: NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.

Home oxygen therapy from the emergency department for COVID-19 an observational study.

STUDY OBJECTIVE: During the COVID-19 pandemic, prescribing supplemental oxygen was a common reason for hospitalization of patients. We evaluated outcomes of COVID-19 patients discharged from the Emergency Department (ED) with home oxygen as part of a program to decrease hospital admissions. METHODS: We retrospectively observed COVID-19 patients with an ED visit resulting in direct discharge or observation from April 2020 to January 2022 at 14 hospitals in a single healthcare system. The cohort included those discharged with new oxygen supplementation, a pulse oximeter, and return instructions. Our primary outcome was subsequent hospitalization or death outside the hospital within 30 days of ED or observation discharge. RESULTS: Among 28,960 patients visiting the ED for COVID-19, providers admitted 11,508 (39.7%) to the hospital, placed 907 (3.1%) in observation status, and discharged 16,545 (57.1%) to home. A total of 614 COVID-19 patients (535 discharge to home and 97 observation unit) went home on new oxygen therapy. We observed the primary outcome in 151 (24.6%, CI 21.3-28.1%) patients. There were 148 (24.1%) patients subsequently hospitalized and 3 (0.5%) patients who died outside the hospital. The subsequent hospitalized mortality rate was 29.7% with 44 of the 148 patients admitted to the hospital dying. Mortality all cause at 30 days in the entire cohort was 7.7%. CONCLUSIONS: Most patients discharged to home with new oxygen for COVID-19 safely avoid later hospitalization and few patients die within 30 days. This suggests the feasibility of the approach and offers support for ongoing research and implementation efforts.

Emergeny Medicine Resident Trauma Intubation Success and Prior Intubation Experience.

BACKGROUND: Emergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents. OBJECTIVES: We attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation. METHODS: We combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest. RESULTS: We included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables. CONCLUSION: We did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.

Predicting falls within 3 months of emergency department discharge among community-dwelling older adults using self-report tools versus a brief functional assessment.

BACKGROUND: Identifying older adults with risk for falls prior to discharge home from the Emergency Department (ED) could help direct fall prevention interventions, yet ED-based tools to assist risk stratification are under-developed. The aim of this study was to assess the performance of self-report and functional assessments to predict falls in the 3 months post-ED discharge for older adults. METHODS: A prospective cohort of community-dwelling adults age 60 years and older were recruited from one urban ED (N = 134). Participants completed: a single item screen for mobility (SIS-M), the 12-item Stay Independent Questionnaire (SIQ-12), and the Timed Up and Go test (TUG). Falls were defined through self-report of any fall at 1- and 3-months and medical record review for fall-related injury 3-months post-discharge. We developed a hybrid-convolutional recurrent neural network (HCRNN) model of gait and balance characteristics using truncal 3-axis accelerometry collected during the TUG. Internal validation was conducted using bootstrap resampling with 1000 iterations for SIS-M, FRQ, and GUG and leave-one-out for the HCRNN. We compared performance of M-SIS, FRQ, TUG time, and HCRNN by calculating the area under the receiver operating characteristic area under the curves (AUCs). RESULTS: 14 (10.4%) of participants met our primary outcome of a fall or fall-related injury within 3-months. The SIS-M had an AUC of 0.42 [95% confidence interval (CI) 0.19-0.65]. The SIQ-12 score had an AUC of 0.64 [95% confidence interval (CI) 0.49-0.80]. The TUG had an AUC of 0.48 (95% CI 0.29-0.68). The HCRNN model using generated accelerometer features collected during the TUG had an AUC of 0.99 (95% CI 0.98-1.00). CONCLUSION: We found that self-report and functional assessments lack sufficient accuracy to be used in isolation in the ED. A neural network model using accelerometer features could be a promising modality but research is needed to externally validate these findings.

Academic springboard: The chief resident position correlates with career path in emergency medicine.

BACKGROUND: The chief resident role often includes additional administrative and educational experiences beyond those of nonchief senior residents. It is unclear to what extent these experiences influence the postresidency career path of those selected as chief residents. The objective of this study was to evaluate the association of chief resident status on immediate postresidency career characteristics relative to nonchief residents in emergency medicine (EM). METHODS: We retrospectively analyzed graduate data from 2016 to 2020 at six accredited EM residency programs. Participating sites were geographically diverse and included 3- and 4-year training formats. Each site abstracted data using a standardized form including program, year of graduation, chief resident status, publications during residency, and immediate postresidency position (academic vs. nonacademic). We calculated descriptive statistics and performed logistic regression to explore differences between the chief resident cohort and other graduates. RESULTS: We gathered information on 365 total graduates (45.8% from 3-year programs and 54.2% from 4-year programs) including 93 (25.5%) chief residents. A total of 129 (35%) graduates assumed an academic position immediately following residency. Fifty-six (60%) of 93 chief residents assumed an academic position immediately following residency, compared to 74 (27%) of 272 other graduates. After program, year of graduation, and number of publications completed during residency were controlled for, chief resident status was a significant predictor of immediate postresidency academic career (odds ratio for a chief resident assuming an academic job = 5.36, 95% confidence interval = 3.10 to 9.27). CONCLUSION: The chief resident role within EM is significantly associated with pursuit of an academic position immediately following residency compared to nonchiefs.

Change in Frequency of Invasive and Noninvasive Respiratory Support in Critically Ill Pediatric Subjects.

BACKGROUND: Noninvasive respiratory support has become more popular in the pediatric population and may prevent or replace invasive procedures, such as endotracheal intubation, in certain circumstances. The objective was to examine the frequency of invasive and noninvasive respiratory support from 2009 to 2017 in critically ill pediatric patients and to determine patient-related factors associated with invasive support using the Virtual Pediatric Systems, LLC database. METHODS: This was an analysis of prospectively collected data on admissions with respiratory support from 17 pediatric ICUs from 2009 to 2017 reported within the Virtual Pediatric Systems database. We determined the frequency of invasive and noninvasive respiratory support over the study period by measuring the number of admissions with either invasive or noninvasive support within a given year divided by the total number of pediatric ICU admissions with respiratory support during the same year. Factors associated with invasive support were examined in univariate and multivariate regressions. RESULTS: A total of 69,262 cases of respiratory support were included. There was a decrease in the rate of invasive support over the study period from 66.9% to 48.5% (P value for test of trend < .001) and an increase in the rate of noninvasive support from 28.7% to 57.7% (P value for test of trend < .001). Trauma cases and subjects < 1 month old were more likely to receive invasive support. Cases occurring in later years and subjects with Black or Hispanic race were less likely to receive invasive support. CONCLUSIONS: From 2009 to 2017, the frequency of admissions with invasive respiratory support decreased, and those with noninvasive respiratory support increased. By 2017, the frequency of noninvasive respiratory support was greater than that of invasive respiratory support.

Association of Initial Illness Severity and Outcomes After Cardiac Arrest With Targeted Temperature Management at 36 °C or 33 °C.

Importance: It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest. Objective: To examine whether illness severity is associated with changes in the association between target temperature and patient outcome. Design, Setting, and Participants: This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation. Exposure: TTM at 36 °C or 33 °C. Main Outcomes and Measures: Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category. Results: Among 1319 patients, 728 (55.2%) had TTM at 33 °C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36 °C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33 °C with TTM at 36 °C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference, -13.8%; 95% CI, -24.4% to -3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies. Conclusions and Relevance: In this study, TTM at 33 °C was associated with better survival than TTM at 36 °C among patients with the most severe post-cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36 °C was associated with better survival among patients with mild- to moderate-severity illness.

Emergency Medicine Residents Experience Acute Stress While Working in the Emergency Department.

INTRODUCTION: Acute stress may impair cognitive performance and multitasking, both vital in the practice of emergency medicine (EM). Previous research has demonstrated that board-certified emergency physicians experience physiologic stress while working clinically. We sought to determine whether EM residents have a similar stress response, and hypothesized that residents experience acute stress while working clinically. METHODS: We performed a prospective observational study of physiologic stress including heart rate (HR), heart rate variability (HRV), and subjective stress in EM residents during clinical shifts in the emergency department. HR and HRV were measured via 3-lead Holter monitors and compared to baseline data obtained during weekly educational didactics. Subjective stress was assessed before and after clinical shifts via a Likert-scale questionnaire and written comments. RESULTS: We enrolled 21 residents and acquired data from 40 shifts. Residents experienced an increase in mean HR of eight beats per minute (P < 0.001) and decrease in HRV of 53.9 milliseconds (P = 0.005) while working clinically. Subjective stress increased during clinical work (P <0.001). HRV was negatively correlated with subjective stress, but this did not reach statistical significance (P = 0.09). CONCLUSION: EM residents experience acute subjective and physiologic stress while working clinically. HR, HRV, and self-reported stress are feasible indicators to assess the acute stress response during residency training. These findings should be studied in a larger, more diverse cohort of residents and efforts made to identify characteristics that contribute to acute stress and to elicit targeted educational interventions to mitigate the acute stress response.

Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.

OBJECTIVES: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal. DESIGN: Retrospective observational cohort study. SETTING: Academic tertiary care hospital. PATIENTS: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria. INTERVENTIONS: Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15-0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients. MEASUREMENTS AND MAIN RESULTS: A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p < 0.01; 95% CI, 0.04-0.49) and had a decreased ICU stay by 2.83 days (95% CI, -5.58 to -0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, -8.40 to 1.08; p = 0.13). CONCLUSIONS: Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated-sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.

Phenotyping Cardiac Arrest: Bench and Bedside Characterization of Brain and Heart Injury Based on Etiology.

OBJECTIVES: Cardiac arrest etiology may be an important source of between-patient heterogeneity, but the impact of etiology on organ injury is unknown. We tested the hypothesis that asphyxial cardiac arrest results in greater neurologic injury than cardiac etiology cardiac arrest (ventricular fibrillation cardiac arrest), whereas ventricular fibrillation cardiac arrest results in greater cardiovascular dysfunction after return of spontaneous circulation. DESIGN: Prospective observational human and randomized animal study. SETTING: University laboratory and ICUs. PATIENTS: Five-hundred forty-three cardiac arrest patients admitted to ICU. SUBJECTS: Seventy-five male Sprague-Dawley rats. INTERVENTIONS: We examined neurologic and cardiovascular injury in Isoflurane-anesthetized rat cardiac arrest models matched by ischemic time. Hemodynamic and neurologic outcomes were assessed after 5 minutes no flow asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. Comparison was made to injury patterns observed after human asphyxial cardiac arrest or ventricular fibrillation cardiac arrest. MEASUREMENTS AND MAIN RESULTS: In rats, cardiac output (20 ± 10 vs 45 ± 9 mL/min) and pH were lower and lactate higher (9.5 ± 1.0 vs 6.4 ± 1.3 mmol/L) after return of spontaneous circulation from ventricular fibrillation cardiac arrest versus asphyxial cardiac arrest (all p < 0.01). Asphyxial cardiac arrest resulted in greater early neurologic deficits, 7-day neuronal loss, and reduced freezing time (memory) after conditioned fear (all p < 0.05). Brain antioxidant reserves were more depleted following asphyxial cardiac arrest. In adjusted analyses, human ventricular fibrillation cardiac arrest was associated with greater cardiovascular injury based on peak troponin (7.8 ng/mL [0.8-57 ng/mL] vs 0.3 ng/mL [0.0-1.5 ng/mL]) and ejection fraction by echocardiography (20% vs 55%; all p < 0.0001), whereas asphyxial cardiac arrest was associated with worse early neurologic injury and poor functional outcome at hospital discharge (n = 46 [18%] vs 102 [44%]; p < 0.0001). Most ventricular fibrillation cardiac arrest deaths (54%) were the result of cardiovascular instability, whereas most asphyxial cardiac arrest deaths (75%) resulted from neurologic injury (p < 0.0001). CONCLUSIONS: In transcending rat and human studies, we find a consistent phenotype of heart and brain injury after cardiac arrest based on etiology: ventricular fibrillation cardiac arrest produces worse cardiovascular dysfunction, whereas asphyxial cardiac arrest produces worsened neurologic injury associated with greater oxidative stress.

Factors associated with advanced cardiac care in prehospital chest pain patients.

INTRODUCTION: Many patients transported by emergency medical services (EMS) may require advanced cardiac care but do not have ST-segment elevation (STEMI) on the initial prehospital EKG. We sought to identify factors associated with the need for advanced cardiac care in undifferentiated EMS patients reporting chest pain in the absence of STEMI on EKG. METHODS: We performed a retrospective analysis of all adult patients, reporting atraumatic chest pain from a single EMS agency, presenting to a single, urban hospital over a 10-year period. Patients with STEMI on prehospital electrocardiogram were excluded. Patient demographics, chest pain characteristics and prehospital factors were abstracted for all patients. We identified those patients that required advanced cardiac care and performed regression analysis to determine associated factors. RESULTS: A total of 956 charts were analyzed. Of this total, 193 patients (20.2%) met the primary composite outcome. Of the outcome group, 185 patients (95.9%) had coronary artery disease documented on cardiac catheterization, 22 patients (11.4%) underwent CABG, and seven patients (3.6%) died in the hospital. Most significant variables (multivariable IRR) included age (1.02), male gender (1.65), history of MI (1.47), PCI (1.66), hyperlipidemia (1.40), diaphoresis (1.51), home aspirin (1.53), and improvement with EMS treatment (1.60). CONCLUSION: We have identified several factors that could be considered when risk stratifying prehospital patients reporting chest pain. While potentially predictive, the factors are broad and support the need for other objective factors that could augment prediction of patients who may benefit from early advanced cardiac care.

Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs.

INTRODUCTION: Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events. METHODS: We performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event. RESULTS: Of 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability. CONCLUSION: In our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.