Implementation of a Novel Residency-Based Electrocardiogram Curriculum Based on Free Open Access Content.

BACKGROUND: Interpretation of the electrocardiogram (ECG) is fundamental in the practice and teaching of emergency medicine. Previous studies have shown that providers of all levels have expressed interest in additional education with ECGs. Asynchronous learning has been shown to be beneficial for improving residents' ability to recognize findings of acute myocardial ischemia. OBJECTIVES: The goal of the study was to know whether a new format based on free, online content would improve residents' ability to interpret ECGs. METHODS: In this 1-year educational pilot study at a single urban teaching hospital, resident physicians participated in a longitudinal curriculum based on free, online content, which was delivered to them electronically on a weekly basis. The study was conducted during the 2016-2017 academic year. Prior to and after the study period, their subjective attitudes toward ECG interpretation, and their objective ability to interpret them successfully, were assessed. RESULTS: Of 42 residents, 25 (59.5%) completed the pre- and post-ECG testing. During the study period, trainees demonstrated improvement in both their subjective attitude toward ECG interpretation and their objective ability to interpret various abnormalities. CONCLUSIONS: Despite some important limitations, we believe this study represents an essential step in the development of training methods for the modern emergency medicine trainee.

Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department.

BACKGROUND: Management of acute shoulder dislocation in the emergency department (ED) is common. OBJECTIVE: This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED. METHODS: The study was a retrospective case-control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts. RESULTS: Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2-22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6-84.3%] vs. 68.0% [95% CI 56.8-77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6-97.3%] vs. 84.0% [95% CI 74.4-91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8-47.6%] vs. 29.3% [95% CI 19.9-40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4-31.0%] vs. 45.3% [95% CI 34.4-56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001). CONCLUSIONS: The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area.

BACKGROUND: The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. OBJECTIVE: This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. METHODS: The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. RESULTS: The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. CONCLUSIONS: Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Characterization and Outcomes of Hospitalized Children With Coronavirus Disease 2019: A Report From a Multicenter, Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) Registry.

OBJECTIVES: Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry. DESIGN: Retrospective study. SETTING: Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry. PATIENTS: Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25-14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16-25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2-7.7 d) and 4 days (1.9-7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased. CONCLUSIONS: In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.

Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study.

Background: Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity. Objective: To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis. Design: Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905). Setting: 7 emergency departments in North America. Participants: Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more. Intervention: Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment. Measurements: Sensitivity of blood cultures obtained after initiation of antimicrobial therapy. Results: Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients. Limitation: Only a proportion of screened patients were recruited. Conclusion: Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation. Primary Funding Source: Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé-Québec, and the Maricopa Medical Foundation.

Risk of contrast extravasation with vascular access in computed tomography.

PURPOSE: Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging. METHODS: The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR). RESULTS: Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21-0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3-5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69-21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61-4.47%) when compared to upper arm catheters. CONCLUSIONS: IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.

Evaluation and Management of the Emergency Department Headache.

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache-which may be broadly categorized into structural, infectious, and vascular causes-is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

Concordance between blood and cerebrospinal fluid cultures in meningitis.

OBJECTIVE: To examine the association between cerebrospinal fluid (CSF) cultures and blood cultures in patients with suspected bacterial or fungal meningitis. METHODS: A 5-year retrospective chart review, conducted from April 2012 to January 2017 of consecutive patient encounters with bacterial or fungal organism growth in CSF culture, when a blood culture was also obtained. Patients were excluded if they received antibiotics prior to either lumbar puncture (LP) or blood culture acquisition, or if CSF cultures were positive for common bacterial skin contaminants. Descriptive statistics were used to characterize the dataset. RESULTS: 21 patient encounters met study inclusion criteria. 13 (61.9%; 95% CI 40.2-80.5%) had blood culture growth of the same organism as the CSF culture. 1 patient had a different organism in the blood culture compared to the CSF culture. 6 patients (33.3%, 95% CI 14.8%-56.9%) with positive CSF cultures had negative blood cultures. CONCLUSIONS: Our results suggest an insufficient degree of agreement between CSF and blood culture results. PCR may be a prudent approach in patients requiring immediate antibiotics and delayed LP.

Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism.

OBJECTIVES: To determine if a physician-patient language barrier impacts the diagnostic accuracy of pulmonary embolism (PE) evaluation. METHODS: A retrospective chart review, conducted between June 2015 and December 2016, of a consecutive sample of diagnostic computed tomography pulmonary angiogram (CTPA) studies performed on adult patients. Positive and negative CTPA scans were further categorized by patient language and the positive diagnostic yield was determined for each language group. A post collection sub-analysis was performed to determine the yield when interpreter services were identified as necessary. RESULTS: The yield for English speaking patients was 10.24% (92/898, 95% CI 8.39% to 12.36%), similar to the yield in Spanish speaking patients of 9.40% (25/266, 95% CI 6.31% to 13.37%, P=0.69). This contrasted with the yield in patients who identified as bilingual, which was significantly lower at 1.41% (1/71, 95% CI 0.07% to 6.75%) compared to both English-(P<0.02) and Spanish-only speakers (P<0.03). The yield for non-English speaking patients who requested an interpreter was 7.37% (14/190, 95% CI 4.26% to 11.77%) versus 3.23% (2/62, 95% CI 0.54% to 10.25%, P=0.25) in those who did not. CONCLUSIONS: The diagnostic yield in English- and Spanish-only speaking patients was similar, however, the yield in those that self-identified as bilingual was significantly lower. In patient groups in which a language barrier existed and an interpreter was not utilized, there was a trend toward a lower diagnostic yield. This suggests an increased propensity to order diagnostic imaging when potential communication barriers exist.