Utility of plain abdominal radiography in adult ED patients with suspected constipation.

BACKGROUND: Abdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained. METHODS: We performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making. RESULTS: Of 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation. CONCLUSION: Plain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

Non-invasive zero-heat-flux technology compared with traditional core temperature measurements in the emergency department.

INTRODUCTION: Core temperatures (Tcore) are often invasive, and can be underutilized. Peripheral temperatures are easier to obtain, but are often less accurate. A zero-heat-flux thermometer (ZHF) is a non-invasive method to obtain core temperatures (TZHF), and has been accurate when compared to Tcore in the operating room. We aimed to determine whether TZHF accurately and reliably measures Tcore in emergency department (ED) patients when compared to rectal, bladder or esophageal temperatures. METHODS: We conducted a prospective observational quality improvement project, with concurrent TZHF and Tcore measurements. The primary outcome was whether one device detected a fever (≥38.1 °C) when the other device did not. Unadjusted linear regression was used to determine the relationship between temperature differences between devices. RESULTS: 268 patients were included. Mean temperatures were 36.6 °C for Tcore and 36.3 °C for TZHF. 16 of 52 patients with fever identified by Tcore were not detected by TZHF, 13 with an infectious etiology. The mean temperature difference between Tcore and TZHF increased as the patient's temperature increased; the difference was 0.2 °C in afebrile patients, but 0.7 °C in febrile patients. CONCLUSION: While we found overall concordance between Tcore and TZHF, the ZHF did not detect fever in 25% of patients presenting with fever of infectious origin. Measurements between Tcore and TZHF varied more as temperatures increased, with TZHF consistently reporting lower values. Although more study is needed, these findings call into question the use of TZHF in the ED where detection of fever frequently guides patient evaluation and management.

Endovascular rewarming in the emergency department for moderate to severe accidental hypothermia.

BACKGROUND: Endovascular temperature control catheters can be utilized for emergent rewarming in accidental hypothermia. The purpose of this study was to compare patients with moderate to severe hypothermia rewarmed with an endovascular temperature control catheter versus usual care at our institution. METHODS: We conducted a retrospective, observational cohort study of patients with moderate to severe accidental hypothermia (core body temperature less than 32°C) in the Emergency Department of an urban, tertiary care medical center. We identified the rewarming techniques utilized for each patient, including those who had an endovascular temperature control catheter placed (Quattro© or Icy© catheter, CoolGuard© 3000 regulation system, Zoll Medical). Rewarming rates and outcomes were compared for patients with and without the endovascular temperature control catheter. We systematically screened for procedural complications. RESULTS: There were 106 patients identified with an initial core temperature less than or equal to 32°C; 52 (49%) patients rewarmed with an endovascular temperature control catheter. Other methods of rewarming included external forced-air rewarming (85, 80%), bladder lavage (17, 16%), gastric lavage (10, 9%), closed pleural lavage (6, 6%), and peritoneal lavage (3, 3%). Rate of rewarming did not differ between the groups with and without catheter-based rewarming (1.3°C/h versus 1.0°C/h, difference 0.3°C, 95% confidence interval [CI] of the difference 0-0.6°C) and neither did survival (70% versus 71%, difference 1%, 95% CI -17 to 20%). We did not identify any significant vascular injuries resulting from endovascular catheter use. CONCLUSION: The endovascular temperature control system was not associated with an increased rate of rewarming in this cohort with moderate to severe hypothermia; however, this technique appears to be safe and feasible.

Extracorporeal membrane oxygenation versus conventional rewarming for severe hypothermia in an urban emergency department.

BACKGROUND: Severe hypothermia (core body temperature < 28°C) is life-threatening and predisposes to cardiac arrest. The comparative effectiveness of different active internal rewarming methods in an urban U.S. population is unknown. We aim to compare outcomes between hypothermic emergency department (ED) patients rewarmed conventionally using an intravascular rewarming catheter or warm fluid lavage versus those rewarmed using extracorporeal membrane oxygenation (ECMO). METHODS: We performed a retrospective cohort analysis of adults with severe hypothermia due to outdoor exposure presenting to an urban ED in Minnesota, 2007-2021. The primary outcome was hospital survival. We also calculated the rewarming rate in the 4 h after ED arrival and compared these data between patients rewarmed with ECMO (the extracorporeal rewarming group) versus without ECMO (the conventional rewarming group). We repeated these analyses in the subgroup of patients with cardiac arrest. RESULTS: We analyzed 44 hypothermic ED patients: 25 patients in the extracorporeal rewarming group (median temperature 24.1°C, 84% with cardiac arrest) and 19 patients in the conventional rewarming group (median temperature 26.3°C, 37% with cardiac arrest; 89% received an intravascular rewarming catheter). The median rewarming rate was greater in the extracorporeal versus conventional group (2.3°C/h vs. 1.5°C/h, absolute difference 0.8°C/h, 95% confidence interval [CI] 0.3-1.2°C/h) yet hospital survival was similar (68% vs. 74%). Among patients with cardiac arrest, hospital survival was greater in the extracorporeal versus conventional group (71% vs. 29%, absolute difference 42%, 95% CI 4%-82%). CONCLUSIONS: Among ED patients with severe hypothermia and cardiac arrest, survival was significantly higher with ECMO versus conventional rewarming. Among all hypothermic patients, ECMO use was associated with faster rewarming than conventional methods.

Screening for QT Prolongation in the Emergency Department: Is There a Better "Rule of Thumb?"

INTRODUCTION: Identification of QT prolongation in the emergency department (ED) is critical for appropriate monitoring, disposition, and treatment of patients at risk for torsades de pointes (TdP). Unfortunately, identifying prolonged QT is not straightforward. Computer algorithms are unreliable in identifying prolonged QT. Manual QT-interval assessment methods, including QT correction formulas and the QT nomogram, are time-consuming and are not ideal screening tools in the ED. Many emergency clinicians rely on the "rule of thumb" or "Half the RR" rule (Half-RR) as an initial screening method, but prior studies have shown that the Half-RR rule performs poorly as compared to other QT assessment methods. We sought to characterize the problems associated with the Half-RR rule and find a modified screening tool to more safely assess the QT interval of ED patients for prolonged QT. METHODS: We created graphs comparing the prediction of the Half-RR rule to other common QT assessment methods for a spectrum of QT and heart rate pairs. We then proposed various modifications to the Half-RR rule and assessed these modifications to find an improved "rule of thumb." RESULTS: When compared to other methods of QT correction, the Half-RR rule appears to be more conservative at normal and elevated heart rates, making it a safe initial screening tool. However, in bradycardia, the Half-RR rule is not sufficiently sensitive in identifying prolonged QT. Adding a fixed QT cutoff of 485 milliseconds (ms) increases the sensitivity of the rule in bradycardia, creating a safer initial screening tool. CONCLUSION: For a rapid and more sensitive screening evaluation of the QT interval on electrocardiograms in the ED, we propose combining use of the Half-RR rule at normal and elevated heart rates with a fixed uncorrected QT cutoff of 485 ms in bradycardia.

Emergency Medicine Resident Shift Work Preferences: A Comparison of Resident Scheduling Preferences and Recommended Schedule Design for Shift Workers.

BACKGROUND: Shift work can negatively impact an individual's health, wellness, and quality of work. Optimal schedule design can mitigate some of these effects. The American College of Emergency Physicians has published schedule design guidelines to increase wellness and longevity in the field, but these guidelines are difficult to apply to emergency medicine (EM) residents given their high shift burdens and other scheduling constraints. Little is known is known about EM resident scheduling preferences or ideal schedule design in the context of residency training. OBJECTIVES: The objectives were to determine whether EM resident schedule design preferences are consistent with current scheduling guidelines for shift workers and to gather information on scheduling practices that are important to residents. METHODS: We surveyed residents at four allopathic EM residency programs and assessed residents' preferences on various schedule design features including shift length, circadian scheduling, night shift scheduling, and impact of schedule design on personal wellness. RESULTS: Of the 144 residents surveyed, 98% of residents felt that their shift schedule was a key factor in their overall wellness. Residents agreed with shift work guidelines regarding the importance of circadian scheduling (65% favorable), although rated the ability to request a day off and have a full weekend off as more important (84 and 78% favorable responses, respectively). Recommended guidelines promote shorter shifts, but only 24% of residents preferred 8-hour shifts compared to 57, 71, and 43% of residents preferring 9-, 10-, and 12-hour shifts, respectively. Sixty-seven percent of residents preferred their nights to be scheduled in one sequence per 4-week period, a night scheduling strategy most at odds with recommended guidelines. CONCLUSIONS: Emergency medicine resident scheduling preferences are not universally consistent with shift work guidelines, likely due to the distinct circumstances of residency training. Residents identify schedule design as a significant factor in their overall wellness.

Evidence-Based Management Of Accidental Hypothermia In The Emergency Department.

Accidental hypothermia is defined as an unintentional drop in core body temperature below 35°C. It can present in any climate and in any season, as it is not always a result of environmental exposure; underlying illnesses or coexisting pathology can play important roles. Although there is some variability in clinical presentation, hypothermia produces a predictable pattern of physiologic responses and clinical manifestations, and effective treatment has yielded many impressive survival case reports. Treatment strategies focus on prevention of further heat loss, volume resuscitation, implementation of appropriate rewarming techniques, and management of cardiac dysrhythmia. Rewarming may be passive or active and/or internal or external, depending on severity and available resources. This issue focuses on methods of effective rewarming and prevention of further morbidity and mortality.