Tranexamic acid for angiotensin converting enzyme inhibitor induced angioedema: A retrospective multicenter study.

BACKGROUND: Angiotensin converting enzyme inhibitors (ACE-Is) prevent the breakdown of bradykinin and can lead to life threatening angioedema. Tranexamic acid is an antifibrinolytic that inhibits formation of precursors involved in bradykinin synthesis and, in case reports, has been described as a potential treatment for ACE-I angioedema. METHODS: This retrospective study included patients who presented to the emergency department (ED) from January 2018 to August 2021 with angioedema while taking an ACE-I. Patients who received tranexamic acid (treatment group) were compared with patients who did not receive tranexamic acid (control group). Primary outcome was length of stay (LOS). Secondary outcomes evaluated included ICU admissions, intubations, and safety events. RESULTS: A total of 262 patients were included in this study (73 treatment; 189 control). Overall, the median ED LOS was longer in the treatment group than controls (20.9 h vs 4.8 h, p < 0.001). ICU admission rates were higher in the treatment group (45% vs 16%, p < 0.001). More patients were intubated in the treatment group (12% vs 3%, p = 0.018). No difference was seen between the treatment group and the controls for return within 7 days, complications related to thrombosis, and death. In patients presenting with severe angioedema symptoms who were admitted to the hospital, median LOS was not different between the two groups (58.7 h vs 55.7 h, p = 0.61). CONCLUSIONS: Patients who received tranexamic acid had increased ED LOS, rates of ICU admission, and need for intubation. This finding may be related to the severity of presentation. Administration of tranexamic acid appears safe to use in ACE-I angioedema. Prospective randomized controlled studies should be considered to determine whether tranexamic acid is an effective treatment for ACE-I angioedema.

Utility of laboratory markers in evaluating for acute compartment syndrome in the emergency department.

BACKGROUND: Acute compartment syndrome is diagnosed by clinical examination with the aid of direct compartmental measurement. Previous work suggested using several laboratory markers that may suggest ongoing acute compartment syndrome in hospitalized patients. Serum creatinine kinase (CK) levels >4000 U/L, chloride (Cl) levels >104 mg/dL, and blood urea nitrogen (BUN) levels <10 mg/dL were found to have 100% association with the diagnosis of acute compartment syndrome. This strategy has not been studied in emergency department (ED) patients. METHODS: A retrospective chart review of all patients diagnosed with acute compartment syndrome of the upper and lower extremity or tibia/fibula fracture was performed from 13 EDs between February 22, 2008 and October 1, 2018. Serum values were collected for each patient: CK, sodium (Na), potassium (K), Cl, bicarbonate (HCO3), glucose, BUN, creatinine (Cr), calcium, lactic acid (LA), and ionized calcium (iCa). A control group composed of patients without acute compartment syndrome who had tibia and/or fibula fractures was analyzed to compare with our cohort. RESULTS: We identified 930 patients who meet inclusion criteria (389 acute compartment syndrome patients and 541 tibia/fibula fracture patients). Sex and ethnicity were similar in each population. A majority of the patients were evaluated at EDs without a trauma center designation. Using univariate modeling, HCO3, CK, iCa, Cr, BUN, and K values were found to be individual significant predictors of acute compartment syndrome (P < 0.05). Multivariate regression models found that HCO3 and Cr were significant predictors of acute compartment syndrome with a C-statistic of 0.77. The Valdez model had a prediction accuracy of 0.52 and a specificity of 99.2% but had a sensitivity of only 2.9%. CONCLUSION: Our model demonstrates that use of serum biomarkers in the ED does aid in the diagnosis of acute compartment syndrome in patients in the ED with 99.2% specificity but has a sensitivity of only 2.9%. Further research and prospective evaluation of serum markers are needed.

Injuries associated with hoverboard use: A review of the National Electronic Injury Surveillance System.

INTRODUCTION: Hoverboards have become popular since they became available in 2015. We seek to provide an estimate of the number of injuries in the United States for 2015 and 2016, and to evaluate differences between adult and pediatric injury complexes. METHODS: We performed a retrospective analysis of the National Electronic Injury Surveillance System (NEISS) from January 1, 2015 to December 31, 2016. Using the weighted design of the NEISS, a nationally representative sample could be determined. RESULTS: During the 2 year period, there were 24,650 hoverboard related injuries (95% confidence interval [Cl], 17,635-31,664) in the US. The average age was 20.9 years old. There were 15,134 pediatric injuries (95%CI 9980-20,287) and 9515 adult injuries (95%CI 7185-11,845). Female patients compromised 51.2% of the sample. The upper extremity was the most common region injured [13,080 (95% CI 8848-17,311)] and fracture was the most common type of injury [10,074 (95% CI 6934-13,213)]. Hoverboard injuries increased from 2416 (95% CL 575-4245) in 2015 to 22,234 (95% CI 16,446-28,020) in 2016. Pediatric patients were more likely to be injured in the upper and lower extremity when compared to their adult cohort (p = 0.0031). Six percent of the cohort [1575 (95% CI 665-2485)] sustained critical injuries with pediatric patients being at 1.46 times higher risk for life threatening injuries. CONCLUSION: Emergency department (ED) visits for hoverboard related injuries appear to be increasing. Pediatric patients are more at risk for hoverboard related injuries than adults and almost 6% of ED visits involved critical injuries, highlighting that hoverboards may be more dangerous than previously recognized.

Shark Related Injuries: A Case Series of Emergency Department Patients.

INTRODUCTION: Shark-related-injuries (SRIs) are not thoroughly evaluated in the medical literature given their rare occurrence. Previous studies involve the utilization of large-independent databases and have demonstrated that shark attacks appear to be increasing, even though mortality of SRIs has decreased from 51% in 1958 to 8.3% in 2001. METHODS: We performed a retrospective chart review on patients presenting to 10 emergency departments (ED) in southeastern Virginia from February 22, 2008 through December 31, 2016. We used a free-text search feature to identify patients documented to have the word "shark" in the record. We reported descriptive statistics for patient demographics, disposition, mortality, time of injury, body injury location, activity during injury, injury severity score (ISS), antibiotic use, and if the patient was in the International Shark Attack File(ISAF) or the Global Shark Attack File(GSAF). RESULTS: We identified 11 patients. Most patients were male (81.8%) and Caucasian (90.9%) with a mean age of 35 years old (SD = 13.4, range17-55). Most patients (72.7%) arrived to the ED by private vehicle. Seventy-eight percent of patients were safely discharged from the ED. There were no deaths. There was a bimodal distribution of the time of injury around noon and early evening. Only 1 of our patients was present in the GSAF and 4 were present in the ISAF. CONCLUSION: Most SRIs can be safely evaluated, treated, and discharged from the ED. Utilization of large databases for shark related research may underestimate its prevalence in the US. Further research is needed into the care of SRIs in the ED.

Injuries Associated with Hoverboard Use: A Case Series of Emergency Department Patients.

INTRODUCTION: Since hoverboards became available in 2015, 2.5 million have been sold in the US. An increasing number of injuries related to their use have been reported, with limited data on associated injury patterns. We describe a case series of emergency department (ED) visits for hoverboard-related injuries. METHODS: We performed a retrospective chart review on patients presenting to 10 EDs in southeastern Virginia from December 24, 2015, through June 30, 2016. We used a free-text search feature of the electronic medical record to identify patients documented to have the word "hoverboard" in the record. We reported descriptive statistics for patient demographics, types of injuries, body injury location, documented helmet use, injury severity score (ISS), length of stay in the ED, and ED charges. RESULTS: We identified 83 patients in our study. The average age was 26 years old (18 months to 78 years). Of these patients, 53% were adults; the majority were female (61.4%) and African American (56.6%). The primary cause of injury was falls (91%), with an average ISS of 5.4 (0-10). The majority of injuries were contusions (37.3%) and fractures (36.1%). Pediatric patients tended to have more fractures than adults (46.2% vs 27.3%). Though 20% of patients had head injuries, only one patient reported using a helmet. The mean and median ED charges were $2,292.00 (SD $1,363.64) and $1,808.00, respectively. Head injuries resulted in a significantly higher cost when compared to other injuries; median cost was $2,846.00. CONCLUSION: While the overall ISS was low, more pediatric patients suffered fractures compared to adults. Documented helmet use was low, yet 20% of our population had head injuries. Further investigation into proper protective gear and training is warranted.

Impact of checklists on peri-intubation care in ED trauma patients.

BACKGROUND: Checklists have successfully been used in intensive care units (ICUs) to improve metrics of critical care. Proper peri-intubation care including use of appropriate induction agents and postintubation sedation is crucial when performing endotracheal intubation (ETI) on critically ill patients, especially in the emergency department (ED). We sought to evaluate the impact of checklists on peri-intubation care in ED trauma patients. METHODS: We performed a retrospective review of all trauma patients intubated in the ED of an urban, level 1 academic center from November 2010 to October 2012. As part of a quality improvement project, a peri-intubation checklist was instituted on November 1, 2011 to guide peri-intubation care. Using a predesign and postdesign, we compared peri-intubation parameters using parametric and nonparametric statistics when appropriate to evaluate the impact of a checklist on peri-intubation care. We also evaluated outcome measures including mortality and lengths of stay. RESULTS: During the 2-year study period, 187 trauma patients underwent ETI in the ED, 90 prechecklist and 97 postchecklist. Rapid sequence intubation (RSI) use was greater with the checklist than without (90.7% vs 75.6%, P=.005). No difference was found between the number of ETI attempts per patient, hemodynamic parameters (heart rate, blood pressure, and oxygen saturation), postintubation anxiolysis, median number of ventilator days, length of ED stay, length of ICU stay, or mortality. CONCLUSION: Peri-intubation checklists result in higher rates of RSI in ED trauma patients but do not alter other measured metrics of peri-intubation care.

Estimates of sedation in patients undergoing endotracheal intubation in US EDs.

BACKGROUND: Sedations after endotracheal intubation (ETI) reduce the risk of self-extubation, uncontrolled pain, and myocardial infarction. Although several small single-center studies demonstrate low rates of sedative drug administration after ETI in the emergency department (ED), little is known regarding post-ETI sedative drug practices nationally. METHODS: We performed a retrospective cohort analysis of the ED portion of the National Hospital Ambulatory Medical Care Survey from 2006 to 2009. We identified all ED patient visits with ETI. Using the multiple probability sampling design of the National Hospital Ambulatory Medical Care Survey, we estimated the proportion of ETI patients receiving pharmacologic sedation, defined as benzodiazepines, opiates, or other sedative agents (propofol, ketamine, etc). We compared patients receiving sedative drugs with those who did not using descriptive statistics and univariable logistic regression. RESULTS: During the 4-year study period, 1071000 patients (95% confidence interval [CI], 839000-1303000) underwent ETI in the ED. Of intubated patients, 46.4% (95% CI, 40.2%-52.7%) received sedative drugs, most commonly benzodiazepines (67.9%). Of patients who survived to hospital admission, 57.4% (95% CI, 48.7%-65.7%) received sedative drugs. Patients were less likely to receive sedation if they were diagnosed with circulatory or cardiac disease (odds ratio, 0.51; P = .026). Use of sedative drugs was not associated with patient age, sex, race, geographic location, or extended ED length of stay (>2 hours). CONCLUSION: Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers.

Local anesthetic-induced protection against lipopolysaccharide-induced injury in endothelial cells: the role of mitochondrial adenosine triphosphate-sensitive potassium channels.

Lidocaine attenuates cell injury induced by ischemic-reperfusion and inflammation, although the protective mechanisms are not understood. We hypothesized that lidocaine and other amide local anesthetics protect against endothelial cell injury through activation of the mitochondrial adenosine triphosphate-sensitive potassium (mitoK(ATP)) channels. We determined the effects of amide local anesthetics (lidocaine, ropivacaine, and bupivacaine), ester local anesthetics (tetracaine and procaine), one amide analog (YWI), and two non-amide local anesthetic analogs (JDA and ICM) on viability of human microvascular endothelial cells after exposure to lipopolysaccharide (LPS) in the absence or presence of the mitoK(ATP) channel antagonist 5-hydroxydecaonate. Flavoprotein fluorescence was used to investigate the effects of local anesthetics on diazoxide-induced activation of mitoK(ATP) channels. Lidocaine, ropivacaine, bupivicaine, YWI, JDA, and ICM attenuated by 60% to 70% the decrease in cell viability caused by LPS. Amide local anesthetics and YWI protection was inhibited by 5-hydroxydecaonate, whereas the protection induced by JDA and ICM was not. Tetracaine and procaine did not protect against LPS-induced injury. The amide local anesthetics and the amide analog (YWI) enhanced diazoxide-induced flavoprotein fluorescence by 5% to 20%, whereas ester local anesthetics decreased diazoxide-induced flavoprotein fluorescence by 5% to 60% and the non-amide local anesthetic analogs had no effect. In conclusion, amide local anesthetics and the amide analog (YWI) attenuate LPS-induced cell injury, in part, through activation of mitoK(ATP) channels. In contrast, tetracaine and procaine had no protective effects and inhibited activation of mitoK(ATP) channels. The non-amide local anesthetic analogs induced protection but through mechanisms independent of mitoK(ATP) channels.