Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital.

STUDY OBJECTIVE: We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. METHODS: We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. RESULTS: Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. CONCLUSION: We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Evaluating the Success Rate of Distal Femur Intraosseous Access Attempts in Pediatric Patients in the Prehospital Setting: A Retrospective Analysis.

OBJECTIVES: Although the proximal tibia is a common site for intraosseous (IO) line placement in pediatric patients, previously published data indicate high malposition rates in infants and children at this location. Although distal femur IO lines generally demonstrate higher flow rates than those at the proximal tibia, to date, there have been no published studies assessing distal femur IO access in pediatric patients. Thus, we aimed to compare the success rates of pediatric IO line insertion attempts between the proximal tibia and the distal femur in a prehospital setting. METHODS: We conducted a retrospective chart review of prehospital pediatric patients who underwent at least one IO line placement attempt by Palm Beach County Fire Rescue from May 2015 to January 2024. We excluded records lacking specific documentation of IO attempt location. We compared the unadjusted success rates of distal femur to proximal tibia, and we also compared success rates after propensity score matching and multivariable logistic regression. Secondarily, we assessed the prehospital complication rate of the IO lines at each anatomical site. RESULTS: We identified 163 pediatric patients who had an IO attempt and were eligible for analysis. Median age was 1.9 years (IQR: 0.46 to 4.2 years). Among those 163 patients, there were 234 vascular access attempts, including 82 IO attempts at the distal femur and 72 at the proximal tibia. The unadjusted success rate of distal femur attempts was 89.0%, compared to 84.7% for proximal tibia attempts, a difference of 4.3% (95% CI -6.4 to 15.0%). After propensity score matching, we found an adjusted odds ratio of 2.0 (95% CI 0.66 to 6.8), favoring the distal femur for successful placement. Prehospital complication rates were similar for distal femur (5.5%) and proximal tibia (4.9%). CONCLUSIONS: This retrospective analysis of pediatric patients in a prehospital setting suggests that IO line placement at the distal femur might offer a marginally higher success rate compared to the proximal tibia. Despite not reaching statistical significance, these findings support the consideration of distal femur as a viable option for IO placement in the pediatric population.

Cash critical care time prices vary substantially by region and hospital ownership: A cross-sectional study.

OBJECTIVES: Emergency department (ED) patients may be billed for critical care time (current procedural terminology codes 99291 and 99292) if they receive at least 30 min of critical care services. We sought to determine the median cash (self-pay) prices for critical care time performed in the ED in the United States and assess for associations between hospital characteristics and prices. METHODS: We performed a cross-sectional analysis of hospital cash prices for critical care time performed in the ED using the first 25 alphabetical states. For each hospital, we recorded hospital characteristics including state, control (nonprofit, governmental, or for-profit), size, teaching status, and system. We then searched for each hospital's cash prices for 99291 and 99292 using Turquoise and hospital websites. We determined the median price for 99291 nationally, regionally, and for large hospital systems. We performed multivariable quantile regression to assess for associations between hospital characteristics and prices for 99291. RESULTS: Of the 2629 eligible hospitals, 2245 (85.4%) and 1893 (72.0%) reported cash prices for 99291 and 99292, respectively. For 99291, the cash price ranged from $45 to $84,775 with a median of $1816 (IQR: $1039-3237). For 99292, the median price was $567 (IQR: $298-1008). On multivariable analysis, hospitals had higher cash prices for 99291 if they were located in the West, for-profit, or part of a large system. In particular, hospitals owned by Tenet Healthcare charged the most for 99291 (median $28,244). CONCLUSION: The cash prices for critical care time vary substantially based on hospital characteristics. In particular, for-profit hospitals and those in the West tend to charge the most. Given that patients who require critical care are unlikely to be able to choose the hospital to which they present, standardization of critical care time fees should be considered.

Low CERVICAL-2 plane block, a proposed regional anesthetic technique for acute cholecystitis.

INTRODUCTION: Acute cholecystitis is a painful inflammatory disease of the gallbladder. The Low Cervical-2 Plane Block is a retrolaminar block that targets the C3, C4, and C5 spinal nerves, which provide sensory innervation to the gallbladder, in order to potentially provide analgesia to patients with pain associated with acute cholecystitis. METHODS: In this brief report, a softly embalmed cadaver was injected with a dye mixture bilaterally. RESULTS: Subsequent cadaveric dissection revealed spread of the injectate deep to the prevertebral fascia to the C4 lamina on the right side and the C5 lamina on the left side. Also, diffusion of the anesthetic over the ligamenta flava could spread inferiorly and laterally to the spinal nerve roots of C3-C5 and thus potentially target the direct sensory innervation of the gallbladder. CONCLUSION: The Low Cervical-2 Plane Block is a potentially effective modality for treating intractable pain from acute cholecystitis. However, further cadaveric injections are needed to confirm the exact extent of spread of anesthetic. Clinical application of the Low Cervical-2 Plane Block in patients with acute cholecystitis is needed to establish the efficacy of this theoretical technique.

Ultrasound-Guided Trigger Point Injections for the Treatment of Neck and Back Pain in the Emergency Department: A Randomized Trial.

OBJECTIVES: Patients frequently present to the emergency department (ED) with neck or back pain, which can be difficult to treat. We sought to compare ultrasound-guided trigger point injection (TPI) to standard medications for patients with neck or back pain. METHODS: We performed a single-center, open label, randomized controlled trial on ED patients with neck or back pain from myofascial pain syndrome comparing ultrasound-guided TPIs to those who received the combination of a nonsteroidal anti-inflammatory drug (NSAID) and a muscle relaxant (MR). The primary outcome of this study was the reduction in mean pain score at the time of ED disposition. RESULTS: In total, we analyzed 196 patients. At the time of ED disposition, patients in the TPI group had a mean reduction in their pain scores of 45.0 mm as compared to 49.9 mm in the NSAID plus MR group (difference: 4.9 [95% confidence interval (CI) -3.0 to 12.7], P = .22). At the first reassessment, patients in the TPI group had greater pain reduction by 10.7 mm (95% CI 3.1 to 18.4). The rate of rescue therapy use was higher in the NSAID plus MR group (difference: 17.5% [95% CI 4.4 to 36.2]). CONCLUSIONS: We found no difference in pain reduction at the time of ED disposition between patients randomized to the ultrasound-guided TPI group as compared to those who received an NSAID plus a MR. However, patients in the TPI group had greater pain reduction at the time of first reassessment and lower rates of rescue therapy use.

Discrepancies in Outcomes by Race and Ethnicity in COVID-19 Patients Receiving Casirivimab and Imdevimab.

OBJECTIVES: The Centers for Disease Control and Prevention has reported increased rates of coronavirus disease 2019 (COVID-19)-related hospitalizations and deaths in Black and Hispanic individuals. One contributing factor to this may be a difference in access to treatment. We thus sought to compare the outcomes of Black, non-Hispanic patients and Hispanic patients with White, non-Hispanic individuals using a group of patients with COVID-19 who received casirivimab/imdevimab. METHODS: This was a secondary analysis of data from a previously published retrospective chart review of patients who received casirivimab/imdevimab for COVID-19 between December 9, 2020 and August 20, 2021, when they were treated at one of three facilities within a single hospital system. We compared the baseline characteristics (including age, sex, body mass index, duration of symptoms, and vaccination status) and outcomes of Black, non-Hispanic patients and Hispanic patients with those of White, non-Hispanic patients. Our primary outcome was the odds of a return visit to the emergency department (ED) within 28 days of treatment as assessed by multivariate logistic regression. We also assessed the rates of return visits to the ED for symptoms caused by COVID-19, hospitalizations, and hospitalizations from hypoxia. RESULTS: In total, 1318 patients received casirivimab/imdevimab for COVID-19 at the three study facilities. Of these, 410 (31.1%) identified themselves as White and non-Hispanic, 88 (6.7%) as Black and non-Hispanic, and 736 (55.8%) as Hispanic. Vaccination rates at the time of treatment were as follows: Black, non-Hispanic 10.2%, Hispanic 13.6%, and White, non-Hispanic 21.5%. On multivariate analysis, the odds of return visits to the ED within 28 days were higher for Black, non-Hispanic patients and Hispanic patients as compared with White, non-Hispanic patients, with odds ratios of 2.8 (95% confidence interval [CI] 1.4-5.5, P = 0.003) and of 2.3 (95% CI 1.5-3.6, P = 0.0002), respectively. For hospitalizations caused by hypoxia within 28 days of treatment, the adjusted odds ratio for Black, non-Hispanic patients was 3.4 (95% CI 1.1-10.5, P = 0.03) as compared with White, non-Hispanic patients. There were no other statistically significant differences among groups in regard to subsequent hospitalizations within 28 days. CONCLUSIONS: Black, non-Hispanic patients and Hispanic patients are more likely to make a return visit to the ED within 28 days after casirivimab/imdevimab treatment for COVID-19 as compared with White, non-Hispanic patients. This holds true even when adjusting for higher vaccination rates among White, non-Hispanic individuals.

The use of additional imaging studies after biliary point-of-care ultrasound in the emergency department.

PURPOSE: We sought to determine the test characteristics of biliary point-of-care ultrasound (POCUS) and to assess the usefulness of obtaining radiology ultrasound (RUS) or cholescintigraphy (HIDA) after biliary POCUS. METHODS: We conducted a retrospective review of emergency department patients who underwent biliary POCUS between May 4, 2018 and November 28, 2021. To be included, patients had to have at least one of the following confirmatory evaluations (considered in this order): surgery, HIDA, RUS, or abdominal CT scan. When a discrepancy existed between the POCUS and the RUS or HIDA, they were compared to a higher criterion standard (if available). RESULTS: Using 348 patients who had a confirmatory evaluation after biliary POCUS, we found the sensitivity and specificity of biliary POCUS for gallstones to be 97.0% (95% CI 92.6 to 99.2%) and 99.5% (95% CI 97.3 to 100%), respectively. For cholecystitis, the sensitivity and specificity were 83.8% (95% CI 72.9 to 91.6%) and 98.6% (95% CI 96.4 to 99.6%), respectively. RUS and POCUS were concordant in 72 (81.8%) of 88 cases in which the patient had both studies while HIDA and POCUS were concordant in 24 (70.6%) of 34 cases. POCUS was deemed correct in at least 50% of discrepant cases with RUS and at least 30% of discrepant cases with HIDA. CONCLUSION: Biliary POCUS has excellent sensitivity and specificity for cholelithiasis; it has lower sensitivity for cholecystitis, but the specificity remains high. Performing a confirmatory RUS or cholescintigraphy after a positive biliary POCUS adds little value, but additional imaging may be useful when POCUS is negative for cholecystitis.

A Comparison of SARS-COV-2 Neutralizing Antibody Therapies in High-Risk Patients with Mild to Moderate COVID-19 Disease at a Single Academic Hospital.

BACKGROUND: Bamlanivimab and casirivimab/imdevimab are recombinant neutralizing monoclonal antibodies that decrease viral load in patients with coronavirus disease 2019 (COVID-19) and can decrease hospitalizations. Few data exist comparing these two therapies. OBJECTIVE: Our aim was to compare the efficacy and safety of bamlanivimab and casirivimab/imdevimab in emergency department (ED) patients with COVID-19 who met criteria for monoclonal antibody therapy. METHODS: We performed a single-center, open-label, prospective study in adult ED patients with confirmed COVID-19 and high-risk features for hospitalization. Enrolled patients received bamlanivimab or casirivimab/imdevimab, depending on the day of the week that they arrived. We observed patients for post-infusion-related reactions and contacted them on days 5, 10, and 30. The primary outcome was the number of hospitalizations through day 30. In addition, we compared groups with regard to return visits to the ED, symptom improvement, antibody-induced adverse events, and deaths. RESULTS: Between December 17, 2020 and January 17, 2021, 321 patients completed the study. We found no statistically significant difference in the rate of subsequent hospitalization between groups (bamlanivimab: n = 18 of 201 [8.9%] and casirivimab/imdevimab: n = 13 of 120 [10.8%]; p = 0.57). In addition, we found no statistically significant differences between groups regarding return visits to the ED or symptom improvement. One patient had a possible adverse reaction to the treatment, and 1 patient died. Both of these events occurred in the bamlanivimab group. CONCLUSIONS: We found no statistically significant differences in rates of subsequent hospitalization or other outcomes for ED patients with COVID-19 when they received bamlanivimab as opposed to casirivimab/imdevimab. Adverse events were rare in both groups.

Is the use of greater than 1 L of intravenous crystalloids associated with worse outcomes in trauma patients?

OBJECTIVE: Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes. METHODS: We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused. RESULTS: Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS. CONCLUSION: On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.

The association of chest pain duration and other historical features with major adverse cardiac events.

OBJECTIVE: We sought to determine if the duration of pain or other features of the history predict major adverse cardiac events (MACE) in patients with chest pain in the emergency department (ED). METHODS: This was a prospective cohort study of patients presenting to a single ED with chest pain. Consenting patients filled out a survey about their symptoms. After 6 weeks, we assessed patients for MACE via chart review and direct contact. We used this data to calculate the likelihood ratios (LRs) of a number of historical features for acute myocardial infarction (MI) (primary endpoint) and MACE within 6 weeks (secondary endpoint). We planned a priori to analyze patients who reported chest pain for ≤1 min or continuously for ≥24 h. RESULTS: We enrolled 1002 patients, and 83.6% had successful 6-week follow up. Regarding chest pain lasting for ≤1 min, the positive LR was 0.95 (95% CI 0.24 to 3.80) for acute MI and 0.67 (95% CI 0.17 to 2.72) for MACE within 6 weeks. The positive LRs of continuous pain lasting ≥24 h for acute MI and MACE within 6 weeks were 0.15 (95% CI 0.04 to 0.58) and 0.36 (95% CI 0.18 to 0.74), respectively. Amongst other historical features assessed, radiation to the right arm was the strongest positive predictor of acute MI. CONCLUSION: Patients with continuous chest pain for ≥24 h are unlikely to have an acute MI. Chest pain lasting ≤1 min does not exclude acute MI.

Blood Culture Results and Overtreatment Associated With the Use of a 1-Hour Sepsis Bundle.

BACKGROUND: Some experts recommend using a 1-h sepsis bundle, but clinical data supporting this strategy are lacking. OBJECTIVES: We aimed to determine the rate of, and clinical predictors for, bacteremia for patients undergoing a 1-h sepsis bundle, and to determine the percentage of "code sepsis" patients who are ultimately diagnosed with sepsis or a bacterial infection. METHODS: This retrospective chart review evaluated code sepsis patients from three emergency departments (EDs) that utilize a 1-h sepsis bundle. The primary outcome was the rate of true-positive blood cultures. Secondarily, we analyzed various clinical factors using logistic regression analysis to determine which are associated with bacteremia. RESULTS: Of the 544 code sepsis patients analyzed, 33.8% (95% confidence interval [CI] 29.9-38.0%) were ultimately diagnosed with sepsis, and 54.6% (95% CI 50.3-58.8%) were diagnosed with a bacterial infection. Exactly 7.0% (95% CI 5.0-9.5%) of the blood cultures performed were true positives. On multivariate logistic regression analysis, temperature > 38°C (100.4°F) or < 36°C (96.8°F), lactate > 4 mmol/L, and indwelling line/device were found to be positively associated with true-positive blood cultures. CONCLUSION: In a group of code sepsis patients from facilities that use a 1-h sepsis bundle, the majority were ultimately not diagnosed with sepsis, and nearly half did not have a bacterial infection. A small minority of patients had bacteremia. Restricting blood culture ordering in patients with possible sepsis to only those who have increased risk for bacteremia could lead to a more judicious use of blood cultures.

I-FiBH trial: intravenous fluids in benign headaches-a randomised, single-blinded clinical trial.

BACKGROUND: Many emergency physicians use an intravenous fluid bolus as part of a 'cocktail' of therapies for patients with headache, but it is unclear if this is beneficial. The objective of this study was to determine if an intravenous fluid bolus helps reduce pain or improve other outcomes in patients who present to the ED with a benign headache. METHODS: This was a randomised, single-blinded, clinical trial performed on patients aged 10-65 years old with benign headaches who presented to a single ED in Las Vegas, Nevada, from May 2017 to February 2019. All patients received prochlorperazine and diphenhydramine, and they were randomised to also receive either 20 mL/kg up to 1000 mL of normal saline (the fluid bolus group) or 5 mL of normal saline (the control group). The primary outcome was the difference between groups in mean pain reduction 60 min after the initiation of treatment. Secondarily, we compared groups with regards to pain reduction at 30 min, nausea scores, the use of rescue medications and disposition. RESULTS: We screened 67 patients for enrolment, and 58 consented. Of those, 35 were randomised to the fluid bolus group and 23 to the control group. The mean pain score dropped by 48.3 mm over 60 min in the fluid bolus group, compared with 48.7 mm in the control group. The between groups difference of 0.4 mm (95% CI -16.5 to 17.3) was not statistically significant (p=0.96). Additionally, no statistically significant difference was found between groups for any secondary outcome. CONCLUSION: Though our study lacked statistical power to detect small but clinically significant differences, ED patients who received an intravenous fluid bolus for their headache had similar improvements in pain and other outcomes compared with those who did not. TRIAL REGISTRATION NUMBER: NCT03185130.

Intravenous fluid bolus rates and pediatric diabetic ketoacidosis resolution.

BACKGROUND: Recent data have challenged the notion that rapid intravenous fluid administration results in adverse neurologic outcomes in children with diabetic ketoacidosis (DKA). While many physicians still administer a cautious 10 cc/kg bolus of intravenous fluids for pediatric DKA patients, there may be benefits to using a larger bolus. METHODS: This was a retrospective chart review of all pediatric patients with DKA presenting to a single emergency department (ED) between 2013 and 2015. Patients who received a bolus of 10 cc/kg or less in the ED were compared to patients who received >10 cc/kg of fluids. The primary outcome was the difference in hospital length-of-stay between the two groups. Secondarily, we compared groups with regards to the time to bicarbonate normalization. RESULTS: In sum, 170 pediatric DKA ED visits were analyzed. Patients who received a 10 cc/kg bolus or less of fluids in the ED had a mean hospital length-of-stay > that was 0.38 days longer (95% CI: 0.006 to 0.75 days) than those who received >10 cc/kg. On multivariable regression analysis, the difference between groups was diminished and no longer statistically significant. The time to bicarbonate normalization was 0.12 days longer (95% CI -0.029 to 0.27) in the 10 cc/kg or less group than the >10 cc/kg group. CONCLUSIONS: After adjustment for confounders, no statistically significant differences in outcomes were seen in pediatric DKA patients who received a 10 cc/kg bolus or less compared to those who received a larger initial bolus.

A Comparison of Headache Treatment in the Emergency Department: Prochlorperazine Versus Ketamine.

STUDY OBJECTIVE: Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED. METHODS: This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache. RESULTS: There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes. CONCLUSION: Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.

A novel technique to intubate patients without reliable pulse oximetry.

Although advances have been made in the approach to airway management, intubating critically ill patients in the Emergency Department (ED) can still be perilous. In some cases, poor peripheral perfusion may preclude obtaining a consistent or reliable pulse oximetry waveform, and the intubator will not accurately know when the patient begins to desaturate. We describe a case of a patient requiring intubation in whom we were unable to obtain a consistent pulse oximetry waveform. We utilized a novel technique in which a Biphasic Cuirass Ventilation (BCV) device was applied to maintain oxygenation and ventilation during the performance of rapid sequence intubation (RSI). This technique has the potential to improve the safety of RSI, especially in the critically ill patient.

Does Intravenous Lactated Ringer's Solution Raise Serum Lactate?

BACKGROUND: Serum lactate increases in states of severe sepsis and shock, but its interpretation may be subject to confounders. Lactated Ringer's solution (LR) is used in the resuscitation of septic patients and contains 28 mmol/L of sodium lactate. OBJECTIVES: We sought to determine if a bolus of 30 mL/kg of LR increases serum lactate levels. METHODS: In this double-blind, randomized controlled trial, 30 volunteers were assigned to receive either 30 mL/kg of intravenous LR or normal saline (NS). Serum lactate was measured before and after the fluid bolus. The primary outcome was the difference in the change in lactate between the LR and NS groups. Secondarily, we assessed the change in pH, bicarbonate, sodium, and chloride in each group. RESULTS: After 30 mL/kg of intravenous LR, the mean serum lactate level increased by 0.93 mmol/L (95% confidence interval 0.42-1.44 mmol/L). However, there was also a small increase in the mean serum lactate level in the NS group of 0.37 mmol/L (95% confidence interval -0.26 mmol/L to 1.00 mmol/L), such that there was not a statistically significant difference in the change in lactate when comparing the LR group to the NS group (p = 0.2). The NS group saw larger declines in pH and bicarbonate and greater increases in chloride compared with the LR group. CONCLUSION: In healthy individuals, a modest but significant rise in mean serum lactate was seen after a 30 cc/kg LR bolus. There was no difference in mean serum lactate when comparing a 30 mL/kg bolus of NS to LR.

Most Transfers from Urgent Care Centers to Emergency Departments Are Discharged and Many Are Unnecessary.

BACKGROUND: Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied. OBJECTIVES: The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred. METHODS: This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance. RESULTS: We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2-37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5-65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private insurance. CONCLUSION: Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society.

Occult Pericardial Tamponade Presenting With Altered Mental Status.

In the pediatric population, cardiac tamponade may present with altered mental status without any clear signs of trauma. Bedside ultrasound is essential to the early diagnosis of this condition. We describe the case of a 5-year-old boy who sustained a potentially fatal, unrecognized trauma to his chest resulting in cardiac tamponade.