Protecting Frontline Workers: Strategies for Preventing and Mitigating Violence in the Emergency Department.

Violence in the emergency department (ED) has been escalating for decades worldwide. High-stress situations are commonplace in the ED and can lead to intentional and unintentional aggression from patients. Staff must be educated on the signs of violence and escalation to recognize potentially dangerous situations early. Staff must also identify underlying medical conditions as the source of unintentional violence. Both situations would require different approaches to management. ED violence negatively affects patient care and leads to long-term harmful outcomes for staff. Multiple strategies for mitigation and prevention have been explored in the literature. Among those, weapon detection systems, de-escalation training, and violence prevention programs have demonstrated improved staff outcomes and decreased violence. Formalized procedures and policies should clearly assign roles for each staff member in the event of a violent patient. Training programs should be instituted and may include self-defense classes or crisis intervention courses. Emergency medicine residency programs and EDs around the country must address the rising incidence of violence within EDs through interdisciplinary policy, procedure development, and prevention and mitigation programs.

Long COVID Illness: Disparities in Understanding and Receipt of Care in Emergency Department Populations.

STUDY OBJECTIVE: Most long coronavirus disease (long COVID) studies rely on traditional surveillance methods that miss underserved populations who use emergency departments (EDs) as their primary health care source. In medically underserved ED populations, we sought to determine (1) whether there are gaps in awareness and self-declared understanding about long COVID illness, and (2) the prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms. METHODS: This study was a cross-sectional, convenience sample survey study of adult patients at 11 geographically representative US EDs from December 2022 to October 2023. Awareness and self-declared understanding about long COVID illness were measured. Prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms were also assessed. RESULTS: Of 1,618 eligible patients, 1455 (89.9%) agreed to participate, including 33.4% African Americans and 30.9% Latino/a. Of the patients, 17.1% lacked primary care. In total, 33.2% had persistent COVID-19 symptoms lasting >1 month, and 20.3% had symptoms >3 months. Moreover, 49.8% with long COVID symptoms missed work/school because of symptoms; 30.3% of all participants and 33.5% of participants who had long COVID symptoms had prior awareness and self-declared understanding of long COVID. Characteristics associated with poor understanding of long COVID were African American race (adjusted odds ratio [aOR] 3.68, 95% confidence interval [CI] 2.66 to 5.09) and Latino/a ethnicity (aOR 3.16, 95% CI 2.15 to 4.64). Participants lacking primary care were less likely to have received long COVID care (24.6% versus 51.2%; difference 26.6%; 95% CI 13.7% to 36.9%). CONCLUSIONS: Despite high prevalence and impact on school/work attendance of long COVID symptoms, most of this ED population had limited awareness and self-declared understanding of long COVID, and many had not received care. EDs should consider the development of protocols for diagnosis, education, and treatment of long COVID illness.

Emergency medicine updates: Upper gastrointestinal bleeding.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION: UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with UGIB.

Emergency medicine updates: Lower gastrointestinal bleeding.

INTRODUCTION: Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician. DISCUSSION: LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition. CONCLUSIONS: An understanding of literature updates can improve the care of patients with LGIB.

Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023.

INTRODUCTION: Low back pain is a common reason for presentation to the Emergency Department (ED). However, there are limited large-scale, recent data on the epidemiology, disposition, and medication administration for this condition. The objective of this was to assess the incidence, admission rates, medication administrations, and discharge prescriptions among ED visits for low back pain in the United States. METHODS: This was a cross-sectional study of ED presentations for low back pain from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits for adults with low back pain identified by ICD-10 codes were included. Outcomes included admission rates, distribution of opioid, benzodiazepine, (non-benzodiazepine) muscle relaxant, acetaminophen, NSAID, and corticosteroid medications administered in the ED, and distribution of opioid, benzodiazepine, muscle relaxant, and corticosteroid medications given upon discharge. Subgroup analyses were performed by specific medication. RESULTS: Of 207,154,419 ED encounters, 12,241,240 (5.9%) were due to back pain with 1,957,299 of these (16.0%) admitted. The admission rate increased over time from 12.8% to 17.1%. The most common medication given in the ED was opioids (40.7%), followed by acetaminophen (37.8%), NSAIDs (22.6%), muscle relaxants (18.4%) benzodiazepines (12.8%), and corticosteroids (5.5%). The most common medications prescribed upon discharge were muscle relaxants (32.1%), followed by opioids (23.2%), corticosteroids (12.2%), and benzodiazepines (3.0%). CONCLUSION: Low back pain represents a common reason for presentation to the ED, and admissions have been increasing over time. Opioids remain the most common ED medication, whereas muscle relaxants have arisen as the most common discharge prescription. These findings can help inform health policy decisions, resource allocation, and evidence-based interventions for medication administration.

Emergency medicine updates: Endotracheal intubation.

INTRODUCTION: Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI. OBJECTIVE: This paper evaluates key evidence-based updates concerning ETI for the emergency clinician. DISCUSSION: ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

Emergency medicine updates: Acute diverticulitis.

INTRODUCTION: Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION: Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Epidemiology of pulmonary embolism diagnosis and management among United States emergency departments over an eight-year period.

INTRODUCTION: Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. However, as diagnostic imaging, risk stratification tools, and treatment have evolved over time, there is a critical need for current data on the incidence, testing, admission rates, and medical management of PE in the ED setting. METHODS: This was a cross-sectional study of ED patients with PE diagnoses from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. ED visits were identified using ICD-10 codes corresponding to acute PE. Chronic PEs were excluded. Outcomes included total ED visits, admission rates, anticoagulant treatment prescribed from the ED, and thrombolytic therapy. Anticoagulant prescriptions included warfarin, enoxaparin, dabigatran, apixaban, rivaroxaban, edoxaban, and betrixaban. Thrombolytic agents included alteplase, tenecteplase, and urokinase. We also assessed changes in the overall rate of CT pulmonary angiograms (CTPA) performed. RESULTS: Out of 186,138,130 total ED encounters, PE represented 531,968 (0.29 %). The overall rate of PE diagnosis rose slowly from 0.20 % in 2016 to a peak of 0.35 % in 2021. Among those with PE, 363,584 (68.3 %) were admitted. The rate of admission declined over time from 75.6 % to 66.1 %. Among those prescribed anticoagulation, the most common medication was apixaban (40.0 %), followed by rivaroxaban (17.3 %), enoxaparin (6.1 %), warfarin (2.6 %), and dabigatran (0.4 %). Thrombolytics were administered in 4.5 % of cases, with the rate of thrombolytics peaking at 5.3 % in 2018 before lowering to 3.5 % in 2023. The overall rate of CTPA increased from 2.4 % to 5.0 %, while the rate of proportion of PEs diagnosed declined from 8.7 % to 6.4 %. CONCLUSION: This study highlights significant shifts in the epidemiology and management of PE within the ED setting. Overall rates of PE rose, while a larger proportion were discharged. Direct oral anticoagulants have become the predominant therapy with the majority of patients receiving apixaban. Thrombolytic use occurs in a small subset and has been declining over time. CTPA rates have risen, while the overall diagnostic yield has declined.

Emergency medicine updates: Transient ischemic attack.

INTRODUCTION: Transient ischemic attack (TIA) is a condition commonly evaluated for in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning TIA for the emergency clinician. DISCUSSION: TIA is a harbinger of ischemic stroke and can result from a variety of pathologic causes. While prior definitions incorporated symptoms resolving within 24 h, modern definitions recommend a tissue-based definition utilizing advanced imaging to evaluate for neurologic injury and the etiology. In the ED, emergent evaluation includes assessing for current signs and symptoms of neurologic dysfunction, appropriate imaging to investigate for minor stroke or stroke risk, and arranging appropriate disposition and follow up to mitigate risk of subsequent ischemic stroke. Imaging should include evaluation of great vessels and intracranial arteries, as well as advanced cerebral imaging to evaluate for minor or subclinical stroke. Non-contrast computed tomography (CT) has limited utility for this situation; it can rule out hemorrhage or a large mass causing symptoms but should not be relied on for any definitive diagnosis. Noninvasive imaging of the cervical vessels can also be used (CT angiography or Doppler ultrasound). Treatment includes antithrombotic medications if there are no contraindications. Dual antiplatelet therapy may reduce the risk of recurrent ischemic events in higher risk patients, while anticoagulation is recommended in patients with a cardioembolic source. A variety of scoring systems or tools are available that seek to predict stroke risk after a TIA. The Canadian TIA risk score appears to have the best diagnostic accuracy. However, these scores should not be used in isolation. Disposition may include admission, management in an ED-based observation unit with rapid diagnostic protocol, or expedited follow-up in a specialty clinic. CONCLUSIONS: An understanding of literature updates concerning TIA can improve the ED care of patients with TIA.

Epidemiology of heart failure presentations to United States emergency departments from 2016 to 2023.

INTRODUCTION: Heart failure (HF) is a common condition prompting presentation to the Emergency Department (ED) and is associated with significant morbidity and mortality. However, there is limited recent large-scale, robust data available on the admission rates, evaluation, and treatment of HF in the ED setting. METHODS: This was a cross-sectional study of ED presentations for HF from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits with ICD-10 codes corresponding to acute HF were included. We excluded congenital heart disease and isolated right-sided HF. Outcomes included percentage of total ED visits, admission rates, troponin, B-type natriuretic peptide (BNP), chest radiography, and diuretic and nitroglycerin medication administration. Subgroup analyses of medications were performed by medication and route of administration (transdermal, sublingual/oral, and intravenous). RESULTS: Out of 190,694,752 ED encounters, 2,626,011 (1.4 %) visits were due to acute HF. Of these, 1,897,369 (72.3 %) were admitted to the hospital. The majority of patients had a troponin (90.3 %), BNP (91.1 %), and chest radiograph (89.5 %) ordered. 82.5 % received intravenous diuresis, while 46.2 % received oral diuresis. The most common diuretic was furosemide (78.4 % intravenous, 32.5 % oral), followed by bumetanide (9.5 % intravenous, 7.1 % oral), and torsemide (0 % intravenous, 8.1 % oral). Nitroglycerin was given in 26.0 %, with the most common route being sublingual/oral (16.6 %), followed by transdermal (9.2 %) and intravenous (3.5 %). CONCLUSION: HF represents a common reason for ED presentation, with the majority of patients being admitted. All patients received diuresis in the ED, with the majority receiving intravenous diuresis with furosemide. Approximately one-quarter received nitroglycerin with the sublingual/oral route being most common. These findings can help inform health policy initiatives, including admission decisions and evidence-based medication administration.

Epidemiology of headache presentations to United States emergency departments from 2016 to 2023.

INTRODUCTION: Headaches are a common condition seen in the Emergency Department (ED), with numerous trials focused on improving care for these patients. However, there is limited recent large-scale, robust data available on the incidence, admission rates, evaluation, and treatment in the ED setting. METHODS: This was a cross-sectional study of ED presentations for headache from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. All ED visits with headache-relevant ICD-10 coding were included. Outcomes included percentage of total ED visits, admission rates, computed tomography (CT) brain imaging, lumbar puncture (LP) performance, and medication administration. Medications were analyzed by class (NSAIDs, acetaminophen, dopamine antagonists, diphenhydramine, opioids, intravenous fluids, caffeine, and magnesium sulfate). Subgroup analyses were performed by specific types of dopamine antagonists. RESULTS: Of 188,482,644 ED encounters, 6,007,090 (3.2%) were due to headache. Of these, 246,082 (4.1%) were admitted. Nearly half (46.6%) of patients received at least one CT. Rates of CT head without contrast increased from 38.2% to 47.9% over time, while rates of CT angiography rose from 2.8% to 10.2%. 1.4% of all patients received an LP, with rates decreasing from 1.8% to 1.1% over time. The most common medication was NSAIDs (45.3%), followed by dopamine antagonists (44.8%), diphenhydramine (38.1%), acetaminophen (24.8%), opioids (16.3%), magnesium sulfate (0.2%), and caffeine (0.1%). 50.8% of patients received intravenous fluids. Rates of opioids declined over time, while dopamine antagonists, acetaminophen, and intravenous fluid administration increased. CONCLUSION: Headaches represent a common reason for ED presentation, with approximately 4% of patients being admitted. Imaging is frequently performed, with rises in CT without contrast and CT angiography rates over time, while LP rates have been declining. NSAIDs remain the most common medication given, with opioids declining over time while non-opioid agents such as dopamine antagonists have increased. These findings can help inform health policy initiatives, such as those focused on radiologic imaging and evidence-based medication administration.

Diagnostic accuracy of artificial intelligence for identifying systolic and diastolic cardiac dysfunction in the emergency department.

INTRODUCTION: Cardiac point-of-care ultrasound (POCUS) can evaluate for systolic and diastolic dysfunction to inform care in the Emergency Department (ED). However, accurate assessment can be limited by user experience. Artificial intelligence (AI) has been proposed as a model to increase the accuracy of cardiac POCUS. However, there is limited evidence of the accuracy of AI in the clinical environment. The objective of this study was to determine the diagnostic accuracy of AI for identifying systolic and diastolic dysfunction compared with expert reviewers. METHODS: This was a prospective, observational study of adult ED patients aged ≥45 years with risk factors for systolic and diastolic dysfunction. Ultrasound fellowship-trained physicians used an ultrasound machine with existing AI software and obtained parasternal long axis, parasternal short axis, and apical 4-chamber views of the heart. Systolic dysfunction was defined as ejection fraction (EF) < 50 % in at least two views using visual assessment or E-point septal separation >10 mm. Diastolic dysfunction was defined as an E:A < 0.8, or ≥ 2 of the following: septal e' < 7 cm/s or lateral e' < 10 cm/s, E:e' > 14, or left atrial volume > 34 mL/m2. AI was subsequently used to measure EF, E, A, septal e', and lateral e' velocities. The gold standard was systolic or diastolic dysfunction as assessed by two independent physicians with discordance resolved via consensus. We performed descriptive statistics (mean ± standard deviation) and calculated the sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of the AI in determining systolic and diastolic dysfunction with 95 % confidence interval (CI). Subgroup analyses were performed by body mass index (BMI). RESULTS: We enrolled 220 patients, with 11 being excluded due to inadequate images, resulting in 209 patients being included in the study. Mean age was 60 ± 9 years, 51.7 % were women, and the mean BMI was 31 ± 8.1 mg/kg2. For assessing systolic dysfunction, AI was 85.7 % (95 %CI 57.2 % to 98.2 %) sensitive and 94.8 % (95 %CI 90.6 % to 97.5 %) specific with a LR+ of 16.4 (95 %CI 8.6 to 31.1) and LR- of 0.15 (95 % CI 0.04 to 0.54). For assessing diastolic dysfunction, AI was 91.9 % (95 %CI 85.6 % to 96.0 %) sensitive and 94.2 % (95 %CI 87.0 % to 98.1 %) specific with a LR+ of 15.8 (95 %CI 6.7 to 37.1) and a LR- of 0.09 (0.05 to 0.16). When analyzed by BMI, results were similar except for lower sensitivity in the BMI ≥ 30 vs BMI < 30 (100 % vs 80 %). CONCLUSION: When compared with expert assessment, AI had high sensitivity and specificity for diagnosing both systolic and diastolic dysfunction.

Diverticulitis evaluation and management among United States emergency departments over an eight-year period.

INTRODUCTION: Diverticulitis is a common reason for presentation to the Emergency Department (ED). However, as imaging options, risk stratification tools, and antibiotic options have expanded, there is a need for current data on the changes in incidence, computed tomography (CT) performance, antibiotic usage, and disposition over time. METHODS: This was a cross-sectional study of ED patients with a diagnosis of diverticulitis from 1/1/2016 to 12/31/2023. Using the Epic Cosmos database, all ED visits for acute diverticulitis were identified using ICD-10 codes. Outcomes included total ED presentations for diverticulitis, admission rates, CTs performed, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients. RESULTS: There were 186,138,130 total ED encounters, with diverticulitis representing 927,326 (0.50 %). The rate of diverticulitis diagnosis increased from 0.40 % to 0.56 % over time. The admission rate declined over time from 33.6 % to 27.7 %, while the CT rate rose from 83.0 % to 92.6 %. Among those discharged, 90.4 % received an antibiotic, which remained consistent over time. Metronidazole (55.1 %) and ciprofloxacin (40.8 %) were the most commonly prescribed antibiotics, followed by amoxicillin-clavulanate (36.1 %). Among those admitted, most received either metronidazole (62.0 %), a fluoroquinolone (40.4 %), a third-generation cephalosporin (18.9 %), or a penicillin-based agent (38.1 %). Among both discharged and admitted patients, there was a marked shift to penicillin-based agents as the primary antibiotic regimen. CONCLUSION: Diverticulitis remains a common ED presentation, with a gradually rising incidence over time. Admission rates have decreased, while CT imaging has become more common. Most patients receive antibiotics, though the specific antibiotic has shifted in favor of penicillin-based agents. These findings can provide key benchmarking data and inform future initiatives to guide imaging and antibiotic use.

Ultrasound-guided paramedian approach: A novel technique for lumbar puncture in the Emergency Department.

Lumbar puncture is performed to evaluate for multiple neurologic conditions, including meningitis and subarachnoid hemorrhage. However, success rates with the landmark-based technique are limited. Ultrasound is most commonly used for pre-marking without dynamic guidance, which presents several limitations, including absence of real-time guidance and lack of reliability if any patient movement occurs after skin marking. We describe a novel, ultrasound-guided paramedian approach which was successfully performed in the Emergency Department setting for lumbar puncture. Physicians should consider this technique as an alternate model using real-time guidance to reduce needle passes in those with difficult anatomy.

Prevalence of undiagnosed stage B heart failure among emergency department patients.

INTRODUCTION: Heart failure (HF) is associated with significant morbidity, mortality, and health care costs. Stage B HF is defined as structural heart disease prior to developing symptomatic HF. If identified early in the disease process, preventative measures may be implemented to slow disease progression to Stage C (symptomatic) or Stage D (refractory) HF. Previous research has focused on outpatient screening for HF in the primary care setting; however, there are limited data on Stage B HF screening in the Emergency Department (ED) setting. The objective of this study was to determine the prevalence of undiagnosed Stage B HF among those with cardiovascular risk factors in the ED setting and identify which risk factors were associated with a greater risk of having Stage B HF. METHODS: A prospective, observational study was performed in a single, urban academic ED from 07/2023 to 05/2024. Inclusion criteria were age ≥ 45 years with hypertension, diabetes, obesity, coronary heart disease, previous cardiotoxic chemotherapy, or family history of HF. Exclusion criteria included signs or symptoms of HF, known history of HF, valvular disease, current atrial fibrillation, or primary language other than English. A focused cardiac ultrasound was performed and interpreted by ultrasound-fellowship trained emergency physicians. Sonographers assessed systolic function as ejection fraction <50 % using visual assessment in at least two different views. Sonographers assessed diastolic dysfunction as an E/A ratio < 0.8, or if ≥2 of the following were present: septal e' < 7 cm/s or lateral e' < 10 cm/s, E/e' ratio > 14, or left atrial volume > 34 mL/m2. Descriptive statistics were performed, followed by comparative analyses and regression modeling. RESULTS: 209 participants were included in the study, with a mean age of 60 years and 51.7 % women. Of these, 125 (59.8 %) had undiagnosed Stage B HF, with 13 (10.4 %) having systolic dysfunction and 112 (89.6 %) having isolated diastolic dysfunction. Among those with isolated diastolic dysfunction, 44 (39.3 %) were grade I, 66 (58.9 %) were grade II, and 2 (1.8 %) were grade III. Predictors of undiagnosed Stage B HF included age (odds ratio 1.06; 95 % CI 1.02 to 1.10) and BMI (odds ratio 1.06; 95 % CI 1.01 to 1.10). CONCLUSION: A large majority of ED patients with cardiovascular risk factors had undiagnosed Stage B HF. Age and obesity were associated with a higher risk of Stage B HF. This provides an opportunity for early identification and intervention for patients with undiagnosed Stage B HF to reduce progression to more severe HF.

Artificial intelligence and point-of-care ultrasound: Benefits, limitations, and implications for the future.

The utilization of artificial intelligence (AI) in medical imaging has become a rapidly growing field as a means to address contemporary demands and challenges of healthcare. Among the emerging applications of AI is point-of-care ultrasound (POCUS), in which the combination of these two technologies has garnered recent attention in research and clinical settings. In this Controversies paper, we will discuss the benefits, limitations, and future considerations of AI in POCUS for patients, clinicians, and healthcare systems.

Malaria: A focused review for the emergency medicine clinician.

INTRODUCTION: Malaria is a potentially fatal parasitic disease transmitted by the Anopheles mosquito. A resurgence in locally acquired infections has been reported in the U.S. OBJECTIVE: This narrative review provides a focused overview of malaria for the emergency clinician, including the epidemiology, presentation, diagnosis, and management of the disease. DISCUSSION: Malaria is caused by Plasmodium and is transmitted by the Anopheles mosquito. Disease severity can range from mild to severe. Malaria should be considered in any returning traveler from an endemic region, as well as those with unexplained cyclical, paroxysms of symptoms or unexplained fever. Patients most commonly present with fever and rigors but may also experience cough, myalgias, abdominal pain, fatigue, vomiting, and diarrhea. Hepatomegaly, splenomegaly, pallor, and jaundice are findings associated with malaria. Although less common, severe malaria is precipitated by microvascular obstruction with complications of anemia, acidosis, hypoglycemia, multiorgan failure, and cerebral malaria. Peripheral blood smears remain the gold standard for diagnosis, but rapid diagnostic tests are available. Treatment includes specialist consultation and antimalarial drugs tailored depending on chloroquine resistance, geographic region of travel, and patient comorbidities. Supportive care may be required, and patients with severe malaria will require resuscitation. Most patients will require admission for treatment and further monitoring. CONCLUSION: Emergency medicine clinicians should be aware of the presentation, diagnosis, evaluation, and management of malaria to ensure optimal outcomes.

Optimal bowel diameter thresholds for diagnosing small bowel obstruction and surgical intervention with point-of-care ultrasound.

OBJECTIVES: A bowel diameter threshold of ≥2.5 cm, originally derived from the research using computed tomography, is frequently used for diagnosing small bowel obstruction (SBO) with point-of-care ultrasound (POCUS). We sought to determine the optimal bowel diameter threshold for diagnosing SBO using POCUS and its accuracy in predicting surgical intervention. METHODS: We conducted a secondary analysis using individual patient-level data from a previous systematic review on POCUS for SBO diagnosis across five academic EDs. Patient data were collected, including imaging results, surgical findings, and final diagnosis. The measured diameter of the small bowel using POCUS was recorded. ROC area under the receiver operating characteristic curves (AUC) were constructed to determine the optimal threshold for bowel diameter in predicting SBO diagnosis and surgical intervention. Subgroup analyses were performed based on sex and age. RESULTS: A total of 403 patients had individual patient-level data available, with 367 patients included in the final analysis. The most accurate bowel diameter overall for predicting SBO was 2.75 cm (AUC = 0.76, 95% CI 0.71-0.81). A bowel diameter of ≤1.7 cm had 100% sensitivity with no miss rate, while a bowel diameter of ≥4 cm had 90.7% specificity in confirming SBO. Patients under 65 had an optimal threshold of 2.75 cm versus 2.95 cm in patients over 65. Females had an optimal threshold of 2.75 cm, while males had a value of 2.95 cm. There was no significant correlation between bowel diameter thresholds and surgical intervention. CONCLUSION: A bowel diameter threshold of 2.75 cm on POCUS is more discriminative diagnostic accuracy for diagnosing SBO. Patients' age and sex may impact diagnostic accuracy, suggesting that tailored approaches may be needed.

Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?

BACKGROUND: Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications. CLINICAL QUESTION: Is phenobarbital an effective treatment for AWS? EVIDENCE REVIEW: Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS. CONCLUSIONS: Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.

Transvenous Pacemaker Placement: A Review for Emergency Clinicians.

BACKGROUND: Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine. OBJECTIVE: This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting. DISCUSSION: Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire. CONCLUSIONS: An understanding of transvenous pacemaker placement is essential for emergency clinicians.