Droperidol Use in the Emergency Department: A Clinical Review.

BACKGROUND: Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question. OBJECTIVE: The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications. DISCUSSION: Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately. CONCLUSIONS: Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.

Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases.

Background: Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation. Objective: The purpose of this study was to describe cases where echocardiography performed at the beginning of the cardiac arrest algorithm offers actionable information to cardiopulmonary resuscitation itself without delaying provision of compressions. Conclusion: Providers using focused echocardiography to evaluate cardiac arrest patients should consider initiating scans at the start of compressions to identify the optimal location for compression delivery and to detect inadequate compressions. Subsequent visualization of full left ventricular compression may be seen after a location change, and combined with end tidal carbon dioxide values, gives indication for improved forward circulatory flow. Although it is not possible in all patients, doing so hastens provision of quality compressions that affect hemodynamic parameters without causing prolongations to the pulse check pause. Further research is needed to determine patient outcomes from both out-of-hospital and in-hospital cardiac arrest when cardiopulmonary resuscitation is visually guided by focused echocardiography.

Wilderness Neurology.

The study of wilderness medicine is within the scope of medical care in the austere environment and addresses medicine as practiced in the setting of delayed access to definitive medical care, hostile environment, limited equipment, and inherent risks to the patient and/or rescuers. Part of this topic includes the care of patients with neurologic illness and/or injury.We will address the five most important skills of a wilderness medicine professional: decision making, prevention, preparation, protocol development, and education by applying the principles to select common neurologic problems that occur in the extended environment: traumatic brain injury, dehydration, hyponatremia, heat illness, hypothermia, spine injury, and lightning injury. We will focus on the most pertinent aspects of wilderness medicine: signs and symptoms, initial stabilization and treatment, evacuation, and extended care.An astute wilderness medicine specialist brings environmental and medical skill sets together to know when it is better to treat in the field and when evacuation, with its inherent risks to the patient and rescuers, is unavoidable.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage.

GOAL: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. MATERIALS AND METHODS: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. FINDINGS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. CONCLUSIONS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

The Present State of Neurointensivist Training in the United States: A Comparison to Other Critical Care Training Programs.

OBJECTIVE: This manuscript describes the state of neurocritical care fellowship training, compares its written standards to those of other critical care fellowship programs, and discusses how programmatic oversight by the United Council for Neurological Subspecialties should evolve to meet American College of Graduate Medical Education standards. This review is a work product of the Society of Critical Care Medicine Neuroscience section and was reviewed and approved by the Council of the Society of Critical Care Medicine. DATA SOURCES: We evaluated the published training criteria and requirements of American College of Graduate Medical Education Critical Care subspecialty fellowships programs of Internal Medicine, Surgery, and Anesthesia and compared them with the training criteria and required competencies for neurocritical care. STUDY SELECTION: We have reviewed the published training standards from American College of Graduate Medical Education as well as the United Council for Neurologic Subspecialties subspecialty training documents and clarified the definition and responsibilities of an intensivist with reference to the Leapfrog Group, the National Quality Forum, and the Joint Commission. DATA EXTRACTION: No data at present exist to test the concept of similarity across specialty fellowship critical care training programs. DATA SYNTHESIS: Neurocritical care training differs in its exposure to clinical entities that are directly associated to other critical care subspecialties. However, the core critical care knowledge, procedural skills, and competencies standards for neurocritical care appears to be similar with some important differences compared with American College of Graduate Medical Education critical care training programs. CONCLUSIONS: The United Council for Neurologic Subspecialties has developed a directed program development strategy to emulate American College of Graduate Medical Education standards with the goal to have standards that are similar or identical to American College of Graduate Medical Education standards.

Dedicated Afternoon Rounds for ICU Patients' Families and Family Satisfaction With Care.

OBJECTIVE: It was hypothesized that adding dedicated afternoon rounds for patients' families to supplement standard family support would improve overall family satisfaction with care in a neuroscience ICU. DESIGN: Pre- and postimplementation (pre-I and post-I) design. SETTING: Single academic neuroscience ICU. PATIENTS: Patients in the neuroscience ICU admitted for longer than 72 hours or made comfort measures only at any point during neuroscience ICU admission. INTERVENTION: The on-service attending intensivist and a neuroscience ICU nursing leader made bedside visits to families to address concerns during regularly scheduled, advertised times two afternoons each week. MEASUREMENTS AND MAIN RESULTS: One family member per patient during the pre-I and post-I periods was recruited to complete the Family Satisfaction in the ICU 24 instrument. Post-I respondents indicated whether they had participated in the afternoon rounds. For primary outcome, the mean pre-I and post-I composite Family Satisfaction in the ICU 24 scores (on a 100-point scale) were compared. A total of 146 pre-I (March 2013 to October 2014; capture rate, 51.6%) and 141 post-I surveys (October 2014 to December 2015; 47.2%) were collected. There was no difference in mean Family Satisfaction in the ICU 24 score between groups (pre-I, 89.2 ± 11.2; post-I, 87.4 ± 14.2; p = 0.6). In a secondary analysis, there was also no difference in mean Family Satisfaction in the ICU 24 score between the pre-I respondents and the 39.0% of post-I respondents who participated in family rounds. The mean Family Satisfaction in the ICU 24 score of the post-I respondents who reported no participation trended lower than the mean pre-I score, with fewer respondents in this group reporting complete satisfaction with emotional support (75% vs. 54%; p = 0.002), coordination of care (82% vs. 68%; p = 0.03), and frequency of communication by physicians (60% vs. 43%; p = 0.03). CONCLUSIONS: Dedicated afternoon rounds for families twice a week may not necessarily improve an ICU's overall family satisfaction. Increased dissatisfaction among families who do not or cannot participate is possible.

History and Perspectives on Nutrition and Hydration at the End of Life.

The question of whether to provide artificial nutrition and hydration (ANH) to a patient with terminal illness or at end of life has been debated over many years. Due to the nature of the question and the setting in which it presents, prospective trials are not feasible, and the health care professional is left to work with the patient and family to make decisions. This perspectives piece addresses the issue in a format designed to inform the reader as to the pertinent considerations around ANH. We briefly review significant historic, religious, ethical, and legal contributions to this discussion and physiologic underpinnings. We address the beliefs of patient, family, and health care providers surrounding this issue. Our goal is to provide a review of the considerations for health care providers as they address this issue with patients and families in the course of compassionate care.

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management : A Position Statement for Healthcare Professionals from the Neurocritical Care Society.

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Emergency medicine residents' knowledge of mechanical ventilation.

BACKGROUND: Although Emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) residency curricula. OBJECTIVES: The objective of this study was to quantify EM residents' education, experience, and knowledge regarding mechanical ventilation. METHODS: We developed a survey of residents' educational experiences with ventilators and an assessment tool with nine clinical questions. Correlation and regression analyses were performed to evaluate the relationship between residents' scores on the assessment instrument and their training, education, and comfort with ventilation. RESULTS: Of 312 EM residents, 218 responded (69.9%). The overall correct response rate for the assessment tool was 73.3%, standard deviation (SD) ± 22.3. Seventy-seven percent (n = 167) of respondents reported ≤ 3 h of mechanical ventilation education in their residency curricula over the past year. Residents reported frequently caring for ventilated patients in the ED, as 64% (n = 139) recalled caring for ≥ 4 ventilated patients per month. Fifty-three percent (n = 116) of residents endorsed feeling comfortable caring for mechanically ventilated ED patients. In multiregression analysis, the only significant predictor of total test score was residents' comfort with caring for mechanically ventilated patients (F = 10.963, p = 0.001). CONCLUSIONS: EM residents report caring for mechanically ventilated patients frequently, but receive little education on mechanical ventilation. Furthermore, as residents' performance on the assessment tool is only correlated with their self-reported comfort with caring for ventilated patients, these results demonstrate an opportunity for increased educational focus on mechanical ventilation management in EM residency training.

Noninvasive Mechanical Ventilation.

This article explains the physiologic basis and fundamentals behind the technology of continuous positive airway pressure, bilevel positive airway pressure, and high flow nasal canula. Additionally, it explores some of the core literature behind their clinical applications. It will also compare HFNC with other noninvasive modalities for respiratory failure alongside clinical titration and weaning algorithms in the emergency department setting.

Qualitative analysis of effective lecture strategies in emergency medicine.

STUDY OBJECTIVE: We empirically identify those aspects that make an effective lecture according to both quantitative and qualitative assessments of the opinions of a select group of emergency medicine educators. METHODS: The authors worked collaboratively with the Educational Meetings Committee of the American College of Emergency Physicians (ACEP) to distribute surveys to 150 participants identified as exemplary lecturers in emergency medicine. These participants had been rated in the top 10% of all lecturers by ACEP's Educational Meetings Committee, according to audience evaluations. Respondents quantitatively rated the importance of a set of strategies for the design/organization and delivery of a lecture. Additional qualitative responses were elicited from semistructured, open-ended questions that were used to identify conceptual themes and subcategories of major themes. RESULTS: One hundred fifty surveys were sent. Seventy-four (49%) of the surveys were returned, of which 67 (45%) were analyzed. Quantitative results revealed the top 3 categories of importance about design/organization (having a manageable scope of content for the allotted time, having clear objectives, and using case-based scenarios) and the top 3 categories of importance about delivery (knowledge of slides/material, having passion/enthusiasm, and interaction with the audience). Qualitative results revealed 5 thematic concepts from the analysis of 281 statements: delivery, vehicle, content, preparation, and uncontrollables, in order of descending importance according to our results. Under the category "delivery," the subcategory "engaging" was the most frequently endorsed quality. "Relevance," under the category "content," was the second most endorsed quality of all the statements obtained. CONCLUSION: Quantitative and qualitative findings indicate that a specific and directed structure, a lecturer's knowledge base, and confidence and enthusiasm for the material are key components in the development of an effective lecture. These self-reported findings help describe strategies of exemplary emergency medicine lecturers that can be considered by faculty, residents, and other presenters.

Training dedicated emergency physicians in surgical critical care: knowledge acquisition and workforce collaboration for the care of critically ill trauma/surgical patients.

BACKGROUND: The Leapfrog Group initiative has led to an increasing public demand for dedicated intensivists providing critical care services. The Acute Care Surgery training initiative promotes an expansion of trauma/surgical care and operative domain, redirecting some of our focus from critical care. Will we be able to train and enforce enough intensivists to care for critically ill surgical patients? METHODS: We have been training emergency physicians (EPs) alongside surgeons in our country's largest Trauma/Surgical Critical Care Fellowship Program annually for more than a decade. We reviewed our Society of Critical Care Medicine Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP, critical care in-training examination) scores from 2006 to 2009 (4 years). The MCCKAP, administered during the ninth month of a Critical Care Fellowship, is the only known standardized objective examination available in this country to compare critical care knowledge acquisition across different specialties. Subsequent workforce outcome for these Emergency Medicine Critical Care Fellowship graduates was analyzed. RESULTS: Over the 4-year period, we trained 42 Fellows in our Program who qualified for this study (30 surgeons and 12 EPs). Surgeons and EP performance scores on the MCCKAP examination were not different. The mean National Board Equivalent score was 419 ± 61 (mean ± standard deviation) for surgeons and 489 ± 87 for EPs. The highest score was achieved by an EP. The lowest score was not achieved by an EP. Ten of 12 (83%) EP Critical Care Fellowship graduates are practicing inpatient critical care in intensive care units with attending physician level responsibilities. CONCLUSIONS: EPs training in a Surgical Critical Care Fellowship can acquire critical care knowledge equivalent to that of surgeons. EPs trained in a Surgical Critical Care paradigm can potentially expand the intensive care unit workforce for Surgical Critical Care patients.

Treating critical illness caused by the 2009 H1N1 influenza A virus.

BACKGROUND: The 2009 H1N1 influenza A pandemic has set the world spinning, unexpectedly producing significant morbidity and mortality in young, otherwise healthy patients. DISCUSSION: As the virus spreads across the Northern Hemisphere, emergency physicians are confronted with the challenging task of caring for the many that become critically ill from this pathogen. With the exception of a few observational studies and case reports, there is little information to guide the emergency physician in resuscitating and delivering critical care to a rapidly deteriorating patient. Many moribund patients with 2009 H1N1 influenza A infection require non-conventional critical care therapies. CONCLUSION: In this article, we describe the case of a critically ill patient with confirmed 2009 H1N1 influenza A infection. After a brief review of the unique characteristics of this virus, we discuss the management of critically ill patients burdened by infection with 2009 H1N1 influenza A.

Gender Disparities in Trauma Care: How Sex Determines Treatment, Behavior, and Outcome.

Trauma data bank and other research reveal sex disparities in trauma care. Risk-taking behaviors leading to traumatic injury have been associated with sex, menstrual cycle timing, and cortisol levels. Trauma patient treatment stratified by sex reveals differences in access to services at trauma centers as well as specific treatments, such as venous thromboembolism prophylaxis and massive transfusion component ratios. Trauma patient outcomes, such as in-hospital mortality, multiple organ failure, pneumonia, and sepsis are associated with sex disparities in the general trauma patient. Outcome after general trauma and specifically traumatic brain injury show mixed results with respect to sex disparity.

House staff communication training and patient experience scores.

OBJECTIVE: To assess whether communication training for housestaff via role-playing exercises (1) is well-received and (2) improves patient experience scores in housestaff clinics. METHODS: We conducted a pre-post study in which the housestaff for 3 adult hospital departments participated in communication trainingled by trained faculty in small groups . Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. Housestaff completed post-training questionnaires. For one month prior to and one month following the training, patients in the housestaff clinics completed surveys with CG-CAHPS questions regarding physician communication, immediately following clinic visits. Pre-and post -intervention results for top-box scores were compared. RESULTS: Forty -four of a possible 45 housestaff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences on patient responses to CG-CAHPS questions were seen when comparing 63 pre-intervention patients surveys to 77 post-intervention surveys. CONCLUSION: Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the "hidden curriculum" of training.

Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head Computed Tomography: A Decision Analysis.

OBJECTIVE: The objective was to determine the testing threshold for lumbar puncture (LP) in the evaluation of aneurysmal subarachnoid hemorrhage (SAH) after a negative head computed tomography (CT). As a secondary aim we sought to identify clinical variables that have the greatest impact on this threshold. METHODS: A decision analytic model was developed to estimate the testing threshold for patients with normal neurologic findings, being evaluated for SAH, after a negative CT of the head. The testing threshold was calculated as the pretest probability of disease where the two strategies (LP or no LP) are balanced in terms of quality-adjusted life-years. Two-way and probabilistic sensitivity analyses (PSAs) were performed. RESULTS: For the base-case scenario the testing threshold for performing an LP after negative head CT was 4.3%. Results for the two-way sensitivity analyses demonstrated that the test threshold ranged from 1.9% to 15.6%, dominated by the uncertainty in the probability of death from initial missed SAH. In the PSA the mean testing threshold was 4.3% (95% confidence interval = 1.4% to 9.3%). Other significant variables in the model included probability of aneurysmal versus nonaneurysmal SAH after negative head CT, probability of long-term morbidity from initial missed SAH, and probability of renal failure from contrast-induced nephropathy. CONCLUSIONS: Our decision analysis results suggest a testing threshold for LP after negative CT to be approximately 4.3%, with a range of 1.4% to 9.3% on robust PSA. In light of these data, and considering the low probability of aneurysmal SAH after a negative CT, classical teaching and current guidelines addressing testing for SAH should be revisited.

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

INTRODUCTION: Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings' education, experience, and knowledge regarding mechanical ventilation in the emergency department. METHODS: We developed a survey of academic EM attendings' educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings' scores on the assessment instrument and their training, education, and comfort with ventilation. RESULTS: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one's own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians' comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. CONCLUSION: EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0-1 hour. Physicians' performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.