Cerebral oximetry monitoring using near-infrared spectroscopy during adult procedural sedation: a preliminary study.

BACKGROUND AND OBJECTIVES: We sought to evaluate the effect of adult procedural sedation on cerebral oxygenation measured by near-infrared spectroscopy (rSo2 levels), and to assess whether respiratory depression occurring during procedural sedation was associated with decreases in cerebral oxygenation. METHODS: We performed a prospective, observational preliminary study on a convenience sample of adult patients (>18 years) undergoing unscheduled procedural sedation in the ED from August 2017 to September 2018 at Hennepin County Medical Center in Minneapolis, Minnesota. The primary outcome measures were rSo2 values by level of sedation achieved and the incidence of cerebral hypoxaemia during procedural sedation (absolute rSo2 ≤60 or decrease ≥20% from baseline). The secondary outcome is the decrease in rSo2 during episodes of respiratory adverse events (AEs), defined by respiratory depression requiring supportive airway measures. RESULTS: We enrolled 100 patients (53% female). The median (IQR) rSo2 values (%) by each level of sedation achieved on the Observer Assessment of Alertness and Sedation (OAAS) scale 1-5, respectively, were 74 (69-79), 74 (70-79), 74 (69-79), 75 (69-80), 72 (68-76). The incidence of cerebral hypoxaemia at any point within the sedation (absolute rSo2 <60%) was 10/100 (10%); 2 out of 10 had rSo2 reduction more than 20% from baseline value; the median (IQR) observed minimum rSo2 in these patients was 58 (56-59). We observed respiratory depression in 65 patients via standard monitoring; of these, 39 (60%) required at least one supportive airway measure, meeting the definition of a respiratory AE. During these AEs, 15% (6/39) demonstrated cerebral hypoxaemia with a median (IQR) minimum rSo2 of 58 (57-59). Four patients (4%) had cerebral hypoxaemia without a respiratory AE. CONCLUSION: Cerebral oximetry may represent a useful tool for procedural sedation safety research to detect potential subclinical changes that may be associated with risk, but appears neither sensitive nor specific for routine use in clinical practice.

The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department.

STUDY OBJECTIVE: We recorded data on the routine use of point-of-care transvaginal ultrasound (POC TVUS) for the evaluation of non-pregnant women with pelvic complaints in the Emergency Department (ED), and sought to determine how it altered the diagnostic impression and management. METHODS: This was a prospective observational study. Adult non-pregnant women with pelvic complaints undergoing POC TVUS were enrolled. Pre and post ultrasound, the treating physician completed a data collection form indicating the most likely cause of the patient's pain, current treatment plan, and expected ultrasound findings. Immediately after the ultrasound, the treating physician completed another form to indicate details about the sonographic process and findings, and whether a radiologyperformed TVUS was planned. RESULTS: Of 113 women enrolled, 79% had both ovaries visualized and the POC TVUS led to changes in plan in 43% of patients, including 3 emergent/urgent interventions; 48% of patients had unexpected findings. Of the 25% who had an additional radiology exam, there were no instances of discordant findings when both ovaries were assessed to be normal on ED Ultrasound. The ultrasound added <10 minutes in 92% of patients. With an ED ultrasound only (n = 85), the median length of stay (LOS) was 282 (IQR 197-323) minutes, compared to 437 (IQR 367-500) minutes when a radiology ultrasound was required (n = 28) (median difference,170 minutes [95% CI 122-212 min]). CONCLUSION: In this study, emergency physicians were able to efficiently obtain and interpret POC TVUS images that changed assessment of non-pregnant women with pelvic pain without significantly increasing the ED length of stay.

Periodic Refresher Emails for Emergency Department Mass Casualty Incident Plans.

Audience and Type of Curriculum: This mass casualty incident (MCI) curriculum is intended for use as refresher content in the months between more formal education, such as hands-on MCI training and drills. The target audience for each topic varies, but the majority of them apply to all disciplines such as direct patient care roles (emergency room technicians, nurses, paramedics, advanced practice practitioners, resident physicians, attending physicians, etc.) and emergency department clerks/coordinators. Topics intended for only one or more discipline are labeled as such. See curriculum chart or email schedule (Appendix AI) for details. Length of Curriculum: This curriculum is intended for use as weekly refresher emails spanning up to a 30-week period. Introduction: There have been an increasing number of mass casualty events occurring throughout the country in recent years, many of which involve penetrating trauma. Education surrounding response to an MCI is broad and has many complex and ever-changing aspects that require staff to be updated on the most current information. Educational Goals: This curriculum is intended to maintain a knowledge base of MCI processes to mitigate degradation of necessary knowledge between hands-on MCI training. Educational Methods: The educational strategies used in this curriculum include short weekly refresher emails and optional external links for further reading. Research Methods: This content was evaluated for efficacy by administering electronic knowledge tests at baseline, mid-way (at 16 weeks), and at the end of the curriculum (32 weeks) via email. Additionally, brief content questions were asked in person while staff members were on shift throughout the entire study period, and a post-study survey was administered in order to obtain staff opinions on email length and training processes in general. Results: Scores for the knowledge tests were slightly higher at the end of the 32 weeks compared to baseline. Subjective feedback was positive overall at the end of the testing period. Discussion: Training and maintaining knowledge of roles and concepts of mass casualty incidents is vital since such events will never happen when expected. Short refresher emails allow educators to use spaced repetition and interleaving methods which have been shown to be a helpful adjunct to maintain knowledge, skills, and attitudes learned in more formal training.1,2. Topics: Mass casualty incident, emergency department, decontamination, blast injury, media relations, biological agents, reprocessing, crisis standard of care, SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage, personal protective equipment, disaster carts, airways, passive security, family reunification.