Point-of-care ultrasound-guided versus standard reduction of displaced distal radius fractures in the emergency department: a randomised controlled clinical trial.

BACKGROUND: During closed reduction of displaced distal radius fractures, physical examination is used to determine the need for further manipulation before radiographic confirmation and cast application. Manipulation performed under ultrasound guidance has the potential to decrease the number of reduction attempts. METHODS: This multicentre randomised controlled trial was undertaken between December 2018 and July 2020 in the ED of four hospitals in the Netherlands. Patients aged ≥16 years presenting to the ED with a distal radius fracture requiring closed reduction were randomised to either point-of-care ultrasound (PoCUS)-guided or standard reduction. The primary outcome was the proportion of patients requiring more than one reduction attempt. The secondary outcomes were time to complete reduction and treatment plan at ED discharge (conservative or operative repair). RESULTS: A total of 214 patients were screened, of which 211 patients were included for primary endpoint analysis (87% female, median age 68 years, 94% dorsal angulation, 59% intra-articular and 73% multifragmentary). In total, 105 patients were randomised to standard treatment and 106 patients to PoCUS-guided fracture reduction. In the standard treatment group, 13 patients (12%) required more than one reduction attempt, compared with 6 patients (6%) in the PoCUS group (OR 2.35, 95% CI 0.86 to 6.45). The median reduction time was 5 min in the PoCUS group (IQR 3-6) vs 3 min (IQR 2-4) in the standard reduction group (p<0.001). At ED discharge, operative repair was indicated for 17 (16%) patients in the standard group and 21 (20%) patients in the PoCUS group (OR 0.78, 95% CI 0.39 to 1.58). CONCLUSION: This study could not demonstrate that PoCUS-guided reduction of distal radius fractures was associated with a statistically significant decrease in the number of reduction attempts. TRIAL REGISTRATION NUMBER: The Netherlands Trial Register (NTR7934).

Haemodynamic effects of a 10-min treatment with a high inspired oxygen concentration in the emergency department: a prospective observational study.

Previous studies show that prolonged exposure to a high inspired oxygen concentration (FiO2) is associated with unfavourable haemodynamic effects. Until now, it is unknown if similar effects also occur after oxygen therapy of limited duration in the emergency department (ED). OBJECTIVES: To investigate the haemodynamic effects of a high FiO2 administered for a limited duration of time in patients who receive preoxygenation for procedural sedation and analgesia (PSA) in the ED. DESIGN, SETTINGS AND PARTICIPANTS: In a prospective cohort study, cardiac output (CO), stroke volume (SV) and systemic vascular resistance (SVR) were measured using the Clearsight non-invasive CO monitoring system in patients who received preoxygenation for PSA in the ED. Measurements were performed at baseline, after 5 min of preoxygenation via a non-rebreathing mask at 15 /L min and after 5 min of flush rate oxygen administration. OUTCOMES MEASURES: The primary outcome was defined as the change in CO (L/min) from baseline after subsequent preoxygenation with 15 L/min and flush rate. RESULTS: Sixty patients were included. Mean CO at baseline was 6.5 (6.0-6.9) L/min and decreased to 6.3 (5.8-6.8) L/min after 5 min of oxygen administration at a rate of 15 L/min, and to 6.2 (5.7-6.70) L/min after another 5 min at flush rate (p=0.037). Mean SV remained relatively constant during this period, whereas mean SVR increased markedly (from 781 (649-1067), to 1244 (936-1695) to 1337 (988-1738) dyn/s/cm-5, p<0.001. Sixteen (27%) patients experienced a>10% decrease in CO. CONCLUSION: Exposure of patients to a high FiO2 for 5-10 min results in a significant drop in CO in one out of four patients. Therefore, even in the ED and in prehospital care, where oxygen is administered for a limited amount of time, FiO2 should be titrated based on deficit whenever this is feasible and high flow oxygen should not be given as a routine treatment.

Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study.

BACKGROUND: Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock. METHODS: In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge. MEASUREMENTS AND MAIN RESULTS: Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44-78) vs 37 (23-47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001). CONCLUSION: The results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.

Association between personal protective equipment and SARS-CoV-2 infection risk in emergency department healthcare workers.

BACKGROUND AND IMPORTANCE: Healthcare personnel working in the emergency department (ED) is at risk of acquiring severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2). So far, it is unknown if the reported variety in infection rates among healthcare personnel is related to the use of personal protective equipment (PPE) or other factors. OBJECTIVE: The aim of this study was to investigate the association between PPE use and SARS-CoV-2 infections among ED personnel in the Netherlands. DESIGN, SETTING AND PARTICIPANTS: A nationwide survey, consisting of 42 questions about PPE-usage, ED layout - and workflow and SARS-CoV-2 infection rates of permanent ED staff, was sent to members of the Dutch Society of Emergency Physicians. Members were asked to fill out one survey on behalf of the ED of their hospital. The association between PPE use and the infection rate was investigated using univariable and multivariable regression analyses, adjusting for potential confounders. OUTCOME MEASURES: Primary outcome was the incidence of confirmed SARS-CoV-2 infections among permanent ED staff between 1 March and 15 May 2020. RESULTS: Surveys were sent to 64 EDs of which 45 responded (70.3%). In total, 164 ED staff workers [5.1 (3.2-7.0)%] tested positive for COVID-19 during the study period compared to 0.087% of the general population. There was significant clustering of infected ED staff in some hospitals (range: 0-23 infection). In 13 hospitals, an FFP2 (filtering facepiece particles >94% aerosol filtration) mask or equivalent and eye protection was worn for all contacts with patients with suspected or confirmed SARS-CoV-2 during the whole study period. The unadjusted staff infection rate was higher in these hospitals [7.3 (3.4-11.1) vs. 4.0 (1.9-6.1)%, absolute difference + 3.3%]. Hospital staff testing policy was identified as a potential confounder of the relation between PPE use and confirmed SARS-CoV-2 infections (collinearity statistic 0.95). After adjusting for hospital testing policy, type of PPE was not associated with incidence of COVID 19 infections among ED staff (P = 0.40). CONCLUSION: In this cross-sectional study, the use of high-level PPE (FFP2 or equivalent and eye protection) by ED personnel during all contacts with patients with suspected or confirmed SARS-CoV-2 does not seem to be associated with a lower infection rate of ED staff compared to lower level PPE use. Attention should be paid to ED layout and social distancing to prevent cross-contamination of ED personnel.

When the factory shuts down.

CLINICAL INTRODUCTION: A 56-year-old man without known medical history was brought to our ED after he was found next to his bed, agitated and with waxing and waning consciousness. He has been bedbound for 5 days after a long-standing period of malnutrition. Physical examination reveals Kussmaul breathing, heart rate of 62/min and blood pressure of 135/100 mm Hg, normal cardiac, abdominal and a non-focal neurological examination other than confusion and altered level of consciousness. An EKG was performed (figure 1).emermed;36/1/51/F1F1F1Figure 1EKG at presentation in our ED. QUESTION: What abnormalities are the clues to the severity of his condition? How would you confirm your suspicion?The minimally prolonged QTc time.The subtle horizontal ST segment elevation in V2 and V3.The subtle positive deflection at the J point.Nothing, this EKG is not interpretable because of the movement of baseline.

Titration of oxygen therapy in critically ill emergency department patients: a feasibility study.

BACKGROUND: Liberal use of oxygen in an emergency situation is common. Today, most health care professionals do not adjust the amount of oxygen given when a saturation of 100% or a PaO2 which exceeds the normal range is reached- which may result in hyperoxia. There is increasing evidence for the toxic effects of hyperoxia. Therefore, it seems justified to aim for normoxia when giving oxygen. This study evaluates whether it is feasible to aim for normoxia when giving oxygen therapy to patients at the emergency department (ED). METHODS: A prospective cohort study was performed at the ED of the University Medical Center Groningen (UMCG). A protocol was developed, aiming for normoxia. During a 14 week period all patients > 18 years arriving at the ED between 8 a.m. and 23 p.m. requiring oxygen therapy registered for cardiology, internal medicine, emergency medicine and pulmonology were included. Statistical analysis was performed using student independent t-test, Mann-Whitney U-test, Fisher's exact test or a Pearson's chi-squared test. RESULTS: During the study period the study protocol was followed and normoxia was obtained after 1 h at the ED in 86,4% of the patients. Patients with COPD were more at risk for not being titrated to normal oxygen levels. CONCLUSIONS: We showed that it is feasible to titrate oxygen therapy to normoxia at the ED. The study results will be used for further research assessing the potential beneficial effects of normoxia compared to hyper- or hypoxia in ED patients and for the development of guidelines.

Oxygen therapy for sepsis patients in the emergency department: a little less?

Liberal oxygen therapy has been a cornerstone in the treatment of critically ill patients. Recently, awareness of hyperoxia toxicity has emerged. We investigated the partial pressure of oxygen in arterial blood (PaO2) in sepsis patients admitted to the emergency department treated with a reduced inspired oxygen fraction of 0.4 instead of 0.6-0.8. A prospective pilot study was carried out over a 3-month period. Patients admitted with two or more SIRS criteria and a suspicion of infection were included. They received 10 l O2/min through a VentiMask 40%. Of 83 patients, 77 had a PaO2 greater than 9.5 kPa with 10 l O2/min, of whom 51 had hyperoxia. Six patients showed hypoxia with 10 l O2/min. Of the hyperoxic patients, 8% died in hospital versus 6% with normoxia. Less than 8% of patients had hypoxia with 10 l O2/min; 66% were hyperoxic. Titration of oxygen therapy to normoxia in the emergency department should be evaluated.