RESUMEN
Objectives: Falls are common in adults aged 65 years and older and are the leading cause of traumatic brain injuries in this age group. Alcohol use may increase the risk of falls as well as the severity of resultant injuries. The aim of this study was to examine the association between self-reported alcohol use and the prevalence of intracranial hemorrhage (ICH) in this patient group. Methods: This was a secondary analysis of the Geriatric Head Trauma Short Term Outcomes Project (GREAT STOP), a study of older adults with blunt head trauma from a fall. We determined the characteristics of every fall event, including patient demographics and medical history, and clinical signs and symptoms related to head trauma. Self-reported alcohol use was categorized as none, occasionally, weekly, or daily. We defined ICH as any acute ICH detected by computed tomography scan. We evaluated the association between alcohol use frequency and ICH, adjusted for patient factors and head injury risk factors. Results: Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use. ICH was more common in patients who used alcohol (20.5%, 22.0%, and 25.1% for occasional, weekly, and daily alcohol users, respectively, vs. 12.0% for non-users, p < 0.001). The frequency of alcohol use was independently associated with ICH, adjusted for patient and head injury risk factors. The adjusted odds ratios (with 95% confidence intervals) for occasional, weekly, and daily alcohol users increased from 2.0 (1.5â2.8) to 2.1 (1.1â4.1) and 2.5 (1.7â3.6), respectively, and showed the characteristics of doseâresponse effect. Conclusions: Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.
RESUMEN
BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.
RESUMEN
Traditionally, emergency medicine (EM) residency programs teach non-adult emergency department activities (such as pediatric EM, point-of-care ultrasound [PoCUS], emergency medical services, and others) in a block format. In this way, a resident may have a 1-month pediatric EM rotation and then not have any further pediatric EM exposure until their next pediatric rotation 6â9 months later. Furthermore, some rotations are only allotted for 1-month during the entire residency. A first-year EM resident may have their only formal PoCUS rotation early in the first year of training when their overall skills are developing, and their level of understanding and retention of information may not be optimal at that juncture of their residency training. This is far from ideal from an educational perspective. Learning scientists have now suggested that a longitudinal interleaved curriculum has substantial advantages over the traditional block format. This curriculum allows for a "spaced retrieval" practice that enhances retention of material and develops thinking processes that are important in clinical practice. The increased continuity of clinical experience has been shown to improve educational outcome and learner satisfaction. We developed a novel longitudinal interleaved curriculum for our EM resident trainees. This curriculum encompasses the entire 3 years of residency training and has the goals of increasing EM knowledge and clinical skills and being excellent preparation for board certification examinations. This concept has clear educational benefits. While adapting an existing medical training program would be challenging, a longitudinal curriculum could be phased in to replace a traditional EM curriculum.
Asunto(s)
Sistemas de Registro de Reacción Adversa a Medicamentos , Vacunas contra la COVID-19 , COVID-19 , Oftalmopatías , Humanos , COVID-19/prevención & control , COVID-19/epidemiología , Vacunas contra la COVID-19/efectos adversos , Oftalmopatías/inducido químicamente , Oftalmopatías/etiología , Estados Unidos/epidemiologíaRESUMEN
STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.
Asunto(s)
Traumatismos Craneocerebrales , Médicos de Atención Primaria , Anciano , Humanos , Traumatismos Craneocerebrales/epidemiología , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Evaluación Geriátrica , Factores de Riesgo , Estudios ProspectivosRESUMEN
Stereoscopic photographs of works in reverse perspective do not reveal their three-dimensional structure whereas pseudoscopic photographs enhance the apparent depth effects.
RESUMEN
BACKGROUND: Although clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. OBJECTIVE: This study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. METHODS: This prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. RESULTS: We enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67-13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67-13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15-12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24-1.99), alcohol use (OR 1.62; 95% CI 1.25-2.09), antiplatelet use (OR 1.84; 95% CI 1.46-2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54-4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. CONCLUSIONS: Although ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.
Asunto(s)
Traumatismos Craneocerebrales , Humanos , Masculino , Anciano , Estudios Prospectivos , Traumatismos Craneocerebrales/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Examen Físico , Servicio de Urgencia en Hospital , Hemorragias Intracraneales , Escala de Coma de Glasgow , Estudios RetrospectivosRESUMEN
Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.
RESUMEN
Objective: Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients. Methods: This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention. Results: Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation. Conclusion: Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.
RESUMEN
The pandemic disrupted our plans to launch a Teaching Academy to formally support medical educators. Moving forward virtually provided a collaborative and supportive network to plan and deliver professional development activities to navigate pandemic challenges. Through sharing and practicing new teaching technologies together, the social connection and engagement with colleagues helped navigate pandemic challenges.
RESUMEN
Patrick Hughes' Reverspectives demonstrate the importance of perspective as a source of information about the structure and layout of the three-dimensional (3D) world. More recently, he has created a new work of art-Hollow Dice-in which the actual concave structure of the dice is seen as convex. In this article, we examine the similarities and differences between these two perceptual phenomena as well as attempting to explain how and why they arise. Popular interest in both effects is based on the fact that "what we perceive" does not correspond to "what the reality is." As a consequence, Reverspectives and Hollow Dice are often categorized and labeled as "illusions." However, if we consider the information that is available in patterns of light reaching our eyes-rather than the "actual" 3D structure of the Reverspectives and the Hollow Dice-we are in a better position to explain how the size, the viewing distance, the perspective features, the convexity bias, and observer movements determine what we see when viewing these novel and fascinating visual effects.
RESUMEN
INTRODUCTION: Ophthalmic diseases of the retina are a significant cause of vision loss globally. Despite much progress, there remains an unmet need for durable, long-acting treatment options. While biologic therapies show great promise, they present many challenges, including complexities in biochemical properties, mechanism of action, manufacturing considerations, preclinical evaluation, and delivery mechanism; these are confounded by the unique anatomy and physiology of the eye itself. AREAS COVERED: This review describes the current development status of intravitreally administered drugs for the treatment of ophthalmic disease, outlines the range of approaches that can be considered for sustained drug delivery to the eye, and discusses key preclinical considerations for the evaluation of ocular biologics. EXPERT OPINION: The required frequency of dosing in the eye results in a great burden on both patients and the health care system, with direct intraocular administration remaining the most reliable and predictable route. Sustained and controlled ophthalmic drug delivery systems will go a long way in reducing this burden. Sustained delivery can directly dose target tissues, improving bioavailability and reducing off-target systemic effects. Maintaining stability and activity of compounds can prevent aggregation and enable extended duration of release, while sustaining dosage and preventing residual polymer after drug depletion.
Asunto(s)
Productos Biológicos , Oftalmopatías , Humanos , Sistemas de Liberación de Medicamentos/métodos , Oftalmopatías/tratamiento farmacológico , Retina , Preparaciones Farmacéuticas , Soluciones Oftálmicas/uso terapéuticoRESUMEN
BACKGROUND: Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. This study aims to evaluate the role of sex in the risk of skull fracture in patients over the age of 65. METHODS: A prospective cohort study was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents. Over a year-long period, consecutive patients aged 65 years and older who presented with blunt head injury were included. Patients who did not receive head CT imaging were excluded. The primary outcome was rate of skull fracture due to the acute trauma, compared by sex. Additional factors examined included patient race/ethnicity and mechanism of injury. RESULTS: Among 5402 patients enrolled, 3010 (56%) were female and 2392 (44%) were male. 4612 (85%) of the head injuries sustained were due to falls, and 4536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2-2.1, p = 0.002). This trend was also seen across race/ethnicity and mechanism of injury. CONCLUSIONS: Older males were found to have a higher rate of skull fractures compared to females after sustaining blunt head trauma, mostly due to falls.
Asunto(s)
Traumatismos Cerrados de la Cabeza , Fracturas Craneales , Humanos , Masculino , Femenino , Anciano , Estudios Prospectivos , Estudios Retrospectivos , Traumatismos Cerrados de la Cabeza/complicaciones , Tomografía Computarizada por Rayos X/efectos adversosRESUMEN
We aimed to 1/develop an observational tool to rate non-verbal cues infants give when being fed 2/test whether these differ between healthy children and those with weight faltering (WF) 3/describe how well these predict whether offered food is eaten. SUBJECTS: and methods: The study used videos of infants eating a standardised meal studied in a case control study nested within the Gateshead Millennium Study (GMS). Infants with weight faltering (WF) were each matched to 2 healthy controls. Half the control videos (N = 28) were used to develop the scale. Food offers were identified and the child's head, eyes, hands, and mouth position/activity rated as signalling a readiness to be fed (engaged), or not (disengaged) as well as whether food was accepted; 5 of these videos were used to assess inter-rater and test-re- test reliability. The scale was then applied to the videos of 28 WF infants (mean age 15.3 months) and 29 remaining controls (mean age 15.8 months) to identify and code all feeding events. RESULTS: test-re-test rates varied from 0.89 for events to 0.74 for head; inter-rater reliability varied from 0.78 for hands to 0.67 for mouth. From 2219 observed interactions, 48% showed at least one engaged element, and 73% at least one disengaged; 67% of interactions resulted in food eaten, with no difference between WF and control. Food was eaten after 73% interactions with any engagement, but also in 62% with disengagement. CONCLUSIONS: Infants were commonly disengaged during meals, but a majority accepted food despite this. Those with weight faltering did not differ compared to healthy controls.
Asunto(s)
Alimentos , Aumento de Peso , Lactante , Humanos , Niño , Estudios de Casos y Controles , Reproducibilidad de los ResultadosRESUMEN
Background: Personal protective equipment (PPE) is effective in preventing coronavirus disease (COVID-19) infection. Resident knowledge of proper use and effective training methods is unknown. We hypothesise that contamination decreases and knowledge increases after a formalised PPE educational session. Methods: Participants included first year interns during their residency orientation in June 2020. Before training, participants took a knowledge test, donned PPE, performed a simulated resuscitation, and doffed. A standardised simulation-based PPE training of the donning and doffing protocol was conducted, and the process repeated. Topical non-toxic highlighter tracing fluid was applied to manikins prior to each simulation. After doffing, areas of contamination, defined as discrete fluorescent areas on participants' body, was evaluated by ultraviolet light. Donning and doffing were video recorded and asynchronously rated by two emergency medicine (EM) physicians using a modified Centers for Disease Control and Prevention (CDC) protocol. The primary outcome was PPE training effectiveness defined by contamination and adherence to CDC sequence. Results: Forty-eight residents participated: 24 internal medicine, 12 general surgery, 6 EM, 3 neurology, and 3 psychiatry. Before training, 81% of residents were contaminated after doffing; 17% were contaminated after training (P<0.001). The most common contamination area was the wrist (50% pre-training vs. 10% post-training, P<0.001). Donning sequence adherence improved (52% vs. 98%, P<0.001), as did doffing (46% vs. 85%, P<0.001). Participant knowledge improved (62%-87%, P <0.001). Participant confidence (P<0.001) and preparedness (P<0.001) regarding using PPE increased with training. Conclusion: A simulation-based training improved resident knowledge and performance using PPE.
RESUMEN
BACKGROUND: Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics. METHODS: This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not. RESULTS: Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p = 0.023) and dyspnea (70.6% vs 29.4%, p = 0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p = 0.010) or hypertension (9.1% vs 0%, p = 0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p = 0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p = 0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found. CONCLUSIONS: Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.
Asunto(s)
Hospitalización , Admisión del Paciente , Humanos , Estudios Retrospectivos , Servicio de Urgencia en Hospital , Disnea/etiología , Disnea/terapia , Unidades de Cuidados Intensivos , Mortalidad HospitalariaRESUMEN
Background and objective The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission from patients with coronavirus disease 2019 (COVID-19) during nebulization is unclear. In this study, we aimed to address this issue. Methods Fugitive emissions of aerosolized saline during nebulization were observed using a standard jet nebulizer fitted with unfiltered and filtered mouthpieces connected via a mannequin to a breathing simulator. Fugitive emissions were observed by using a laser sheet and captured on high-definition video, and they were measured by using optical particle counters positioned where a potential caregiver may be administering nebulization and three other locations in the sagittal plane at various distances downstream of the mannequin. Results The use of a standard unfiltered mouthpiece resulted in significant emission of fugitive aerosols ahead of and above the mannequin (spread over 2 m in front). A mouthpiece with a filter-adaptor effectively suppressed the emissions, with only minor leakage from the nebulizer cup. Particle count measurements supported the visual observations, providing total particle count levels and aerosol concentration levels at the measurement locations. The levels decayed slowly with downstream distance. Conclusions The visualization described above captured the dispersion of emitted aerosols in the plane of the laser sheet, aligned with the sagittal plane. The particle count measurements provided temporal and spatial distributions of the aerosol concentration levels over the time and locations considered. However, the exhaled air and aerosolized droplets spread three-dimensionally in front of and above the mannequin. The results visually highlight the effectiveness of using a filtered mouthpiece in suppressing the fugitive aerosols and identify an approach for limiting the occupational exposure of healthcare workers to these emissions while administering nebulized therapies.
RESUMEN
Background: As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic. Methods: This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February. Results: A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001). Conclusions: The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.
RESUMEN
Objective There have been many efforts to research and produce treatment modalities for COVID-19. Monoclonal antibodies have been one of the effective treatments since their approval by the US Food and Drug Administration (FDA) under emergency use authorization (EUA) in 2020. This study surveyed COVID-19 patients about their disease course and experience with monoclonal antibody treatment. Methods Patients who received monoclonal antibody treatment between February 12, 2021, and June 2, 2021, at a South Florida community hospital were enrolled in the study. This included patients over 18 years of age with a confirmed positive COVID-19 test result, with mild to moderate symptoms within 10 days of onset and identified as high risk for progression to severe disease. There were no exclusion criteria. After 30 days, patients were followed up via a structured telephone survey regarding subsequent emergency department (ED) visits for worsening COVID-19 symptoms, need for oxygenation, intubation, and death. Secondary outcomes were adverse effects and patient perceptions. Results Among the 119 patients who received monoclonal antibodies during the established time frame, 93 (78.1%) consented to participate in the telephone survey. Of these, 11.8% had a subsequent visit to the ED for worsening COVID-19 symptoms, 6.5% required oxygen, and 2.2% were admitted to the intensive care unit (ICU). There were no reported intubations or deaths. The vast majority (91.4%) would recommend monoclonal antibody treatment to others. Conclusion Patients who received monoclonal antibody therapy had low rates of subsequent ED visits and rarely required oxygen or ICU admission. The majority of patients would recommend treatment with monoclonal antibodies to others.
RESUMEN
INTRODUCTION: The use of hydroxychloroquine has dramatically increased since being touted as a potential therapeutic in combating coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus. This newfound popularity increases the risk of accidental pediatric ingestion, whereby just one or two tablets causes morbidity and mortality from seizures, cardiac dysrhythmias, and cardiogenic shock. The unique management of hydroxychloroquine overdose makes it imperative for emergency medicine physicians to have familiarity with treating this condition. Similarly, ââduring the COVID-19 pandemic, there have been publicized cases touting extracts of oleander as being a potential therapeutic against the illness. Since it is commonly available and potentially lethal ingestion with a possible antidote, we developed a simulation case based on the available literature. The two cases were combined to create a pediatric toxicology curriculum for emergency medicine residents and medical students. Both of these treatments were selected as simulation cases since they were being touted by prominent national figures as potential cures for COVID-19. METHODS: Two series of simulation cases were conducted in a high-fidelity simulation lab with emergency medicine residents and medical students. The hydroxychloroquine simulation case involved the management of a four-year-old male who presented to the emergency department with nausea, vomiting, and tachycardia after ingesting hydroxychloroquine tablets. As the case unfolded, the child became increasingly unstable, eventually experiencing QT prolongation, torsades de pointes, and ventricular fibrillation arrest requiring appropriate resuscitation to achieve a return of spontaneous circulation. The oleander simulation case involved the management of a three-year-old male who presented to the emergency department with nausea, vomiting, and tachycardia after ingesting parts of an unknown plant. As that case progresses, the child becomes increasingly unstable, eventually experiencing atrial fibrillation, bradycardia, and degenerating into pulseless electrical activity and cardiac arrest requiring appropriate resuscitation to achieve the return of spontaneous circulation. Both series of simulation cases were modifiable based on trainee level and had the ability to include ancillary emergency department staff. RESULTS: Each simulation case was performed six times at our simulation center, with a total of 22 learners for the hydroxychloroquine case, and 14 for the oleander case. Through pre- and post-simulation confidence assessments, learners demonstrated increases in knowledge of toxidromes, evaluating pediatric overdoses, treating cardiac dysrhythmias, performing pediatric advanced life support, and managing post-arrest care. Learners also demonstrated improvements in recognizing the unique treatment of hydroxychloroquine and oleander toxicity, the toxic dose of both substances in a child, and the most common electrolyte anomaly seen in each toxicity. DISCUSSION: Simulation training enables learners to manage rare and complex disease processes. These cases were designed to educate trainees in recognizing and treating rare overdoses of emerging "therapeutics" that were touted early in the COVID-19 pandemic.