Tranexamic acid for angiotensin converting enzyme inhibitor induced angioedema: A retrospective multicenter study.

BACKGROUND: Angiotensin converting enzyme inhibitors (ACE-Is) prevent the breakdown of bradykinin and can lead to life threatening angioedema. Tranexamic acid is an antifibrinolytic that inhibits formation of precursors involved in bradykinin synthesis and, in case reports, has been described as a potential treatment for ACE-I angioedema. METHODS: This retrospective study included patients who presented to the emergency department (ED) from January 2018 to August 2021 with angioedema while taking an ACE-I. Patients who received tranexamic acid (treatment group) were compared with patients who did not receive tranexamic acid (control group). Primary outcome was length of stay (LOS). Secondary outcomes evaluated included ICU admissions, intubations, and safety events. RESULTS: A total of 262 patients were included in this study (73 treatment; 189 control). Overall, the median ED LOS was longer in the treatment group than controls (20.9 h vs 4.8 h, p < 0.001). ICU admission rates were higher in the treatment group (45% vs 16%, p < 0.001). More patients were intubated in the treatment group (12% vs 3%, p = 0.018). No difference was seen between the treatment group and the controls for return within 7 days, complications related to thrombosis, and death. In patients presenting with severe angioedema symptoms who were admitted to the hospital, median LOS was not different between the two groups (58.7 h vs 55.7 h, p = 0.61). CONCLUSIONS: Patients who received tranexamic acid had increased ED LOS, rates of ICU admission, and need for intubation. This finding may be related to the severity of presentation. Administration of tranexamic acid appears safe to use in ACE-I angioedema. Prospective randomized controlled studies should be considered to determine whether tranexamic acid is an effective treatment for ACE-I angioedema.

Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage.

Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.

In acute stroke with a large ischemic region, endovascular therapy improved functional status at 90 d.

SOURCE CITATION: Yoshimura S, Sakai N, Yamagami H, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022;386:1303-13. 35138767.

HIV post-exposure prophylaxis in the emergency department: An updated assessment and opportunities for HIV prevention identified.

OBJECTIVES: Research suggests nonoccupational post exposure prophylaxis (nPEP) is under prescribed for people seeking treatment within 72 h of human immunodeficiency virus (HIV) exposures in the emergency department (ED). This study is an assessment of ED prescribers' knowledge, attitudes and practices regarding administration of HIV nPEP. METHODS: This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED participants at work over a 4-month period from 5 hospital-based and 2 freestanding EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. RESULTS: The majority of those surveyed (133/149, 89.3%) believe it is their responsibility to provide HIV nPEP in the ED. Although 91% (138/151) and 87% (132/151) of participants are willing to prescribe nPEP for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Only 25% (37/151) of participants prescribed nPEP in the last year. Participants considered time (27%), connecting patients to follow-up (26%), and cost to patients (23%), as barriers to prescribing nPEP. CONCLUSIONS: This study identified perceived barriers to administration of nPEP and missed opportunities for HIV prevention in the ED. Although most ED prescribers were willing to prescribe nPEP and felt it is their responsibility to do so, the majority of prescribers were not confident in prescribing it. The most commonly cited barriers to prescribing nPEP were time and access to follow-up care.

Correction: Correction to 'Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department' [Annals of Emergency Medicine 68 (2016) 354-370.e29].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Past blood alcohol concentration and injury in trauma center: propensity scoring.

BACKGROUND: Evidence linking alcohol use to injury outcomes remains inconclusive, with prehospital and police department-based studies showing negative effects and hospital-based studies showing no effect or better outcomes. OBJECTIVE: The purpose of this study was to examine the relationship of blood alcohol concentration (BAC) with injury characteristics and outcomes among trauma patients admitted to a major teaching hospital. In an effort to mitigate selection and confounding bias, propensity scoring methodology was applied, by which trauma patients were randomly assigned to high- and low-BAC groups. METHODS: Electronic medical records were retrospectively reviewed for a period of 8 months. Of 1057 patients whose BAC was determined, 667 had BAC ≤ 0.08 g/dL and 390 had BAC > 0.08 g/dL. Injury characteristics were defined as injury type, injury location, and trauma level. Injury outcomes were defined as hospitalization, length of hospital stay, and in-hospital death. Adjusted odds ratios (aOR) and their 95% confidence intervals (CI) were calculated using multivariate logistic regression models and propensity scoring was applied. RESULTS: A positive relationship was observed between BAC and unintentional injury (aOR = 1.08; 95% CI 1.01-1.17). Although injuries of the extremities were less likely to occur in patients with high BAC (aOR = 0.88; 95% CI 0.80-0.98), head injury was positively associated with high BAC (aOR = 1.27; 95% CI 1.14-1.42). Also, Level I trauma patients had nearly 60% greater odds of having a high BAC than Level II trauma patients. CONCLUSIONS: A high alcohol level in the blood appears to be predictive of more unintentional injury, head injury, and Level I trauma activation and less injuries in extremities.

Geographic Location and Corporate Ownership of Hospitals in Relation to Unfilled Positions in the 2023 Emergency Medicine Match.

Introduction: In the 2023 National Resident Matching Program (NRMP) match, there were 554 unfilled emergency medicine (EM) positions before the Supplemental Offer and Acceptance Program (SOAP). We sought to describe features of EM programs that participated in the match and the association between select program characteristics and unfilled positions. Methods: The primary outcome measures included the proportion of positions filled in relation to state and population density, hospital ownership type, and physician employment model. Secondary outcome measures included comparing program-specific attributes between filled and unfilled programs, including original accreditation type, year of original accreditation, the total number of approved training positions, length of training, urban-rural designation, hospital size by number of beds, resident-to-bed ratio, and the percentage of disproportionate share patients seen. Results: The NRMP Match had 276 unique participating EM programs with 554 unfilled positions. Six states offered 52% of the total NRMP positions available. Five states were associated with two-thirds of the unfilled positions. Public hospitals had a statistically significant higher match rate (88%) when compared to non-profit and for-profit hospitals, which had match rates of 80% and 75%, respectively (P < 0.001). Programs with faculty employed by a health system had the highest match rate of 87%, followed by clinician partnerships at 79% and private equity groups at 68% (P < 0.001 overall and between all subgroups). Conclusion: The 2023 match in EM saw increased rates in the number of residency positions and programs that did not fill before the SOAP. Public hospitals had higher match rates than for-profit or non-profit hospitals. Residency programs that employed academic faculty through the hospital or health system were associated with higher match rates.

ACR Appropriateness Criteria® Cerebrovascular Diseases-Stroke and Stroke-Related Conditions.

Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Decreasing D-dimer after recent negative computed tomographic pulmonary angiogram does not rule out pulmonary embolism.

An algorithmic approach to testing utilizing risk stratification and quantitative D-dimer has been considered an acceptable approach to ruling out pulmonary embolism (PE). When D-dimer is elevated, further testing for PE is indicated. However, no evidence exists to guide practitioners when patients return after a recent negative workup for PE who previously had an elevated D-dimer. This case describes a patient who initially had an elevated D-dimer with negative workup for PE who, on repeat visit, had a decreasing D-dimer but was diagnosed with a PE. When evaluating patients after a negative workup for PE after an elevated D-dimer, a decrease in D-dimer cannot be used to rule out PE.

ACR Appropriateness Criteria® Workup of Noncerebral Systemic Arterial Embolic Source.

Noncerebral systemic arterial embolism, which can originate from cardiac and noncardiac sources, is an important cause of patient morbidity and mortality. When an embolic source dislodges, the resulting embolus can occlude a variety of peripheral and visceral arteries causing ischemia. Characteristic locations for noncerebral arterial occlusion include the upper extremities, abdominal viscera, and lower extremities. Ischemia in these regions can progress to tissue infarction resulting in limb amputation, bowel resection, or nephrectomy. Determining the source of arterial embolism is essential in order to direct treatment decisions. This document reviews the appropriateness category of various imaging procedures available to determine the source of the arterial embolism. The variants included in this document are known arterial occlusion in the upper extremity, lower extremity, mesentery, kidneys, and multiorgan distribution that are suspected to be of embolic etiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Left Lower Quadrant Pain: 2023 Update.

The differential diagnosis for left lower quadrant pain is wide and conditions range from the benign and self-limited to life-threatening surgical emergencies. Along with patient history, physical examination, and laboratory tests, imaging is often critical to limit the differential diagnosis and identify life-threatening abnormalities. This document will discuss the guidelines for the appropriate use of imaging in the initial workup for patients who present with left lower quadrant pain, patients with suspected diverticulitis, and patients with suspected complications from diverticulitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Tinnitus: 2023 Update.

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Answering the myth: use of emergency services on Friday the 13th.

OBJECTIVE: The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and emergency department (ED) visits. METHODS: This was a retrospective chart review of all ED visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6 hospital-based EDs. Thirteen unlikely conditions were evaluated as well as total ED volumes. As a control, the Friday before and after and the month before and after were used. χ(2) Analysis and Wilcoxon rank sum tests were used for each variable, as appropriate. RESULTS: A total of 49 094 patient encounters were evaluated. Average ED visits for Friday the 13th were not increased compared with the Friday before and after and the month before. However, compared with the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7, P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95% confidence interval, 1.04-2.61). No other category was noted to have an increase risk on Friday the 13th compared with the control dates. CONCLUSIONS: Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day.

The utility of wet prep in predicting Neisseria gonorrhoeae and Chlamydia trachomatis.

BACKGROUND: Diagnosing Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) cervical infections can be difficult in the Emergency Department without real-time testing, as historical and physical elements are known to be unreliable. OBJECTIVE: To evaluate the utility of the vaginal wet mount preparation (wet prep) in predicting an infection with NG or CT. METHODS: A retrospective chart review was performed on 12 months of data from September 2007 to August 2008 on patients aged 18 years and above who had a chief complaint requiring a pelvic examination and had concurrent testing for NG/CT and a wet prep. Wet preps were analyzed and reported as quantity of white cells and clue cells present (none, few, moderate, or many) as well as the presence of Trichomonas vaginalis (TV). Wet prep results were evaluated to see if there was a correlation with NG/CT. RESULTS: There were 2439 patient encounters reviewed. A total of 373/2439 (15.3%) patient encounters were positive for NG or CT; 272/2439 (11.2%) were positive for TV, whereas 966/2439 (39.6%) had white cells and 995/2439 (40.8%) had clue cells on wet prep. Clue cells and TV did not correlate with the presence of NG or CT. Only the presence of "moderate" and "many" white cells correlated with NG or CT (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.12-2.22 and OR 2.47, 95% CI 1.86-3.27, respectively). CONCLUSION: In patients who are diagnosed with NG or CT, the presence of TV or clue cells on wet prep is an unreliable marker for diagnosis. However, having moderate or many white cells present on wet prep does increase the probability of concurrent NG or CT infection and may be used in cases where the clinical suspicion is equivocal.