Use of Topical Anesthetics in the Management of Patients With Simple Corneal Abrasions: Consensus Guidelines From the American College of Emergency Physicians.

The management of corneal abrasions has largely excluded dispensing topical local anesthetics for home use due to concern for corneal toxicity. We have reviewed and critically appraised the available literature evidence regarding the use of topical anesthetics in patients with simple corneal abrasions. Using sequential Delphi review, we have developed these clinical guidelines. Herein are evidentiary summaries and consensus recommendations for 8 specific relevant questions. Our key observation is that for only simple corneal abrasions, as diagnosed and treated in accordance with the full protocol described herein, it appears safe to prescribe or otherwise provide a commercial topical anesthetic (ie, proparacaine, tetracaine, oxybuprocaine) for use up to every 30 minutes as needed during the first 24 hours after presentation, as long as no more than 1.5 to 2 mL total (an expected 24-hour supply) is dispensed and any remainder is discarded after 24 hours. Importantly, although published findings suggest absent harm for short courses, more rigorous studies with a greater cumulative sample size and ophthalmologic follow-up are needed.

Nationwide Aquatic Envenomations Reported to US Poison Control Centers from 2011 to 2020.

INTRODUCTION: Aquatic envenomations are common injuries along the coastal United States that pose a public health risk and can cause significant morbidity. We examined aquatic envenomation exposures that were called in to poison control centers (PCC) in the United States from 2011 to 2020. METHODS: The Association of Poison Control Center's (AAPCC) National Poison Data System was queried for all aquatic envenomations reported during the 10 y period from January 1, 2011, to December 31, 2020. Data collected included date, exposure and geographic location, patient age and sex, signs and symptoms, management setting, treatments, and clinical outcome. Duplicated records, confirmed nonexposure, and reports not originating within the United States were excluded. RESULTS: There were 8517 human aquatic envenomations reported during the study period, 62% (5243) of whom were male; 56% (4264) of patients were 30 y or younger. There were an average of 852 calls per year, with 46% of calls occurring during June to August. California, Texas, and Florida had the highest number of envenomations during the study period. Fish (61%; 5159) and Cnidaria (30%; 2519) envenomations were the most common exposures. Overall, 37% (3151) of exposures were treated in healthcare facilities, with no deaths reported. CONCLUSIONS: The highest proportion of aquatic envenomations occurred among younger males (≤30 y) during the summer months. While rarely leading to major adverse events, aquatic envenomations were commonly reported injuries to PCC and occurred in all 50 states. Poison control centers continue to be real-time sources of information and data regarding aquatic envenomation trends.

Corporate Control of Emergency Departments: Dangers from the Growing Monster.

BACKGROUND: Corporate control in emergency departments (EDs) has increased during the past 20 years through hospital consolidation and the growth of ED contract management groups. OBJECTIVES: To describe the growing corporate influence in the practice of emergency medicine and associated dangers to the public's safety and well-being. DISCUSSION: Hospital systems through mergers and acquisitions have created regional monopolies providing them the power to charge high fees, which can lead to economic hardship for patients. Hospitals have also increasingly employed physicians and can exert influence over their practice to further increase profits. ED contract management groups (CMGs) obtain the exclusive contract for emergency services and gain control over the livelihood of emergency physicians, decreasing their autonomy and inserting the business interest into the physician-patient relationship, and this may result in harm to patients. Safety issues identified by emergency physicians may not be articulated for fear of being fired, and protocols may direct physicians to order unneeded testing and encourage unnecessary hospital admissions to make higher profits. Of additional concern, some CMGs are involved in graduate emergency medicine education, exposing physicians in training to corporate influence during their formative years. CONCLUSIONS: Given the potential harm to patients due to corporate influence, there must be serious consideration for legislative or regulatory solutions regarding the increasing corporate control of emergency medicine in the United States.

Outcomes for in-hospital cardiac arrest for COVID-19 patients at a rural hospital in Southern California.

BACKGROUND: In-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California. METHODS: Single-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition. RESULTS: Twenty-one patients were identified, most of whom were Hispanic, male, and aged 50-70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged. CONCLUSION: At a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings.

Large Cerebellar Stroke in a Young COVID-19-Positive Patient: Case Report.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most frequently presents with respiratory symptoms, such as fever, dyspnea, shortness of breath, cough, or myalgias. There is now a growing body of evidence that demonstrates that severe SARS-CoV-2 infections can develop clinically significant coagulopathy, inflammation, and cardiomyopathy, which have been implicated in COVID-19-associated cerebrovascular accidents (CVAs). CASE REPORT: We report an uncommon presentation of a 32-year-old man who sustained a large vessel cerebellar stroke associated with a severe COVID-19 infection. He presented with a headache, worse than his usual migraine, dizziness, rotary nystagmus, and dysmetria on examination, but had no respiratory symptoms initially. He was not a candidate for thrombolytic therapy or endovascular therapy and was managed with clopidogrel, aspirin, and atorvastatin. During hospital admission he developed COVID-19-related hypoxia and pneumonia, but ultimately he was discharged to home rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the growing number of reports of neurologic and vascular complications, such as ischemic CVAs, in otherwise healthy individuals who are diagnosed with SARS-CoV-2 infection. A brief review of the current literature will help elucidate possible mechanisms, risk factors, and current treatments for CVA associated with SARS-CoV-2.

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes.

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non-ST-elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? (2) In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? (3) In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events? (4) Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Grow the Pie: Interdepartmental Cooperation as a Method for Achieving Operational Efficiency in an Emergency Department.

BACKGROUND: Despite sufficient literature analyzing macroscopic and microscopic methods of addressing emergency department (ED) operations, there is a paucity of studies that analyze methods between these extremes. OBJECTIVE: We conducted a quasi-experimental study incorporating a pre/post-intervention comparison to determine whether interdepartmental cooperation is effective at improving ED operations by combining microscopic and macroscopic concepts. METHODS: We performed an analysis of operational and financial data from a cooperative investment in imaging transport personnel between the emergency and radiology departments. Our primary outcome, order to table time (OTT), measured imaging times by modality (computed tomography [CT], ultrasound [US], magnetic resonance imaging [MRI]). These were compared for statistically significant change before and after the intervention. Our secondary outcome, gross profit, was calculated using the revenue generated from gained outpatient studies minus the associated direct personnel costs. RESULTS: Transporters improved OTTs by decreasing median imaging times from 132 min to 116 min (p < 0.0005). Efficiency improved for CT scans with median time decreasing from 142 min to 114 min (p < 0.0005). Transport hires had adverse effects on US, with an increase in median OTT from 91 min to 99 min (p < 0.018). MRI experienced a similar trend in OTT, as median times worsened from 215 min to 235 min (p < 0.225). The investment in transporters generated a gross profit of $1.03 million for the radiology department over 9 months. CONCLUSIONS: Interdepartmental cooperation is a broadly applicable macroscopic method that is effective at achieving microscopic, site-specific gains in ED efficiency. Transporters provided operational gains for the ED and financial gains for the radiology department.

Correction: Correction to 'Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures' [Annals of Emergency Medicine 63 (2014) 437-447.e15].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

The accuracy of emergency department medication history as determined by mass spectrometry analysis of urine: a pilot study.

BACKGROUND: Emergency Department (ED) medication lists (ML) are considered inaccurate based on previous comparisons of ED ML with patients' self-reporting of medications and reviews of patients' pharmacy and medical records. OBJECTIVE: To determine the accuracy of ED ML using mass spectrometry analysis of urine samples. METHODS: This was a prospective observational study conducted at an urban tertiary care university hospital. Convenience sampling of patients who underwent ED triage was done. Included were patients 18 years or older who were capable of providing informed consent and who reported use of at least one medication. Excluded were patients unable to consent, prisoners, non-English-speaking patients, and patients unwilling or unable to provide a urine sample. Mass spectrometry analysis was performed on enrolled patients' urine, and their ED triage ML were recorded. Urinalysis results were compared to ED triage ML. Concordance between respective ED triage ML and urinalysis results was determined. Medications were grouped by medication class. The top five discrepant medication classes were identified. RESULTS: There were 100 patients enrolled; 21 patients, although eligible, did not provide a urine sample and were excluded, and one patient withdrew. Mean age was 51 years, and 54 patients were male. Twenty-two medication classes were identified. No patient had 100% concordance of ED triage ML and urinalysis results. Opioid analgesic, sedative hypnotics, cardiac, psychiatric, and nonopioid analgesic medications were the top discrepant medication classes. CONCLUSIONS: ED triage ML obtained by patient recall are inaccurate when compared to medications detected in urine using mass spectrometry analysis.

Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures.

This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures? (2) In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events? (3) In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures? (4) In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.

An observational case series of dabigatran and rivaroxaban exposures reported to a poison control system.

OBJECTIVE: Characterize clinical presentations and outcomes of dabigatran and rivaroxaban exposures reported to a poison control system. METHODS: Data for cases of dabigatran and rivaroxaban exposures called into the California Poison Control System from January 2011 to July 2013 were collected. Data collected included patient demographics, type of exposure, medication, dosage, vital signs, laboratory values, interventions, outcomes, and disposition. Exclusion criteria included confirmed nonexposures or miscoded cases. RESULTS: A total of 56 cases were identified, with 7 excluded, leaving 37 dabigatran and 12 rivaroxaban cases. Children age 12 years or less accounted for 5 dabigatran and 2 rivaroxaban cases. Bleeding was reported in 15 dabigatran cases. There were 4 cases of acute self-harm overdose with dabigatran ranging from 1800 to 3900 mg. Mild bleeding was reported in only one of these overdose cases. There were 2 fatal hemorrhages in dabigatran cases, both in chronic therapeutic dosing. Bleeding was reported in 5 rivaroxaban cases, all in patients with chronic exposure; no deaths were reported. There were no adverse outcomes in pediatric patients. Coagulation parameters did not correlate well with bleeding. CONCLUSIONS: In our series, the greatest risk of adverse events was in patients chronically taking these agents, irrespective of excess dosing. Acute self-harm ingestions and accidental pediatric ingestions had few adverse effects, although massive overdose can lead to abnormal coagulation studies. It does not appear that single low-dose ingestions of either medication will lead to clinically significant bleeding. It may be possible to manage some pediatric exposures and most accidental ingestions with observation.

Use of sotrovimab in vaccinated versus unvaccinated COVID-19 patients in a resource-limited emergency department during the omicron surge.

Objective: The treatment of outpatient COVID-19 patients at high risk of disease progression has been challenging, as both the virus and available therapeutics change. Here, we sought to evaluate the effect of vaccination status on the use of sotrovimab during the early phase of the Omicron surge. Methods: This was a retrospective observational study performed at El Centro Regional Medical Center, a rural hospital on the southern Californian border. The electronic medical record was queried for all emergency department (ED) patients who received an infusion of sotrovimab between January 6 and February 6, 2022. We obtained patient demographics, COVID-19 vaccination status, medical comorbidities, and whether patients returned to the ED within 30 days. We stratified our cohort according to vaccination status and performed a multivariable logistic regression model to evaluate the relationship between these factors. Results: One hundred seventy patients received an infusion of sotrovimab in the ED. The patient cohort had a median age of 65 years, 78.2% were Hispanic, and obesity (63.5%) was the most common comorbidity. A total of 73.5% of patients were vaccinated against COVID-19. A total of 12/125 (9.6%) of vaccinated patients returned to the ED within 30 days, versus 10/45 (22.2%) in the unvaccinated cohort, which was statically significant (P = 0.03). The presence of medical comorbidities was not associated with the primary outcome. Conclusion: Of patients who received sotrovimab, those who were vaccinated were less likely to return to the ED within 30 days compared to those who were unvaccinated. Given the effectiveness of the COVID-19 vaccination campaign, and with the emergence of new variants, it is unclear what role monoclonal antibody therapy should play in the treatment of outpatient COVID-19 patients.

ICU Admission Risk Factors for Latinx COVID-19 Patients at a U.S.-Mexico Border Hospital.

OBJECTIVE: Few studies have examined the impact of coronavirus disease 2019 (COVID-19) on the primarily Latinx community along the U.S.-Mexico border. This study explores the socioeconomic impacts which contribute to strong predictors of severe COVID-19 complications such as intensive care unit (ICU) hospitalization in a primarily Latinx/Hispanic U.S.-Mexico border hospital. METHODS: A retrospective, observational study of 156 patients (≥ 18 years) Latinx/Hispanic patients who were admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at a U.S.-Mexico border hospital from April 10, 2020, to May 30, 2020. Descriptive statistics of sex, age, body mass index (BMI), and comorbidities (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease). Multivariate regression models were produced from the most significant variables and factors for ICU admission. RESULTS: Of the 156 hospitalized Latinx patients, 63.5% were male, 84.6% had respiratory failure, and 45% were admitted to the ICU. The average age was 67.2 (± 12.2). Those with body mass index (BMI) ≥ 25 had a higher frequency of ICU admission. Males had a 4.4 (95% CI 1.58, 12.308) odds of ICU admission (p = 0.0047). Those who developed acute kidney injury (AKI) and BMI 25-29.9 were strong predictors of ICU admission (p < 0.001 and p = 0.0020, respectively). Those with at least one reported comorbidity had 1.98 increased odds (95% CI 1.313, 2.99) of an ICU admission. CONCLUSION: Findings show that age, AKI, and male sex were the strongest predictors of COVID-19 ICU admissions in the primarily Latinx population at the U.S.-Mexico border. These predictors are also likely driven by socioeconomic inequalities which are most apparent in border hospitals.

Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

INTRODUCTION: Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19. METHODS: Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14. RESULTS: Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19. CONCLUSION: De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19. TRIAL REGISTRATION: Clinicaltrials.gov NCT04366050.