Showing papers in "American Journal of Emergency Medicine in 2018"

A systematic review of the pain scales in adults: Which to use?

Abstract: Objective The study analysed the Visual Analogue Scale (VAS), the Verbal Rating Scale (VRS) and the Numerical Rating Scale (NRS) to determine: 1. Were the compliance and usability different among scales? 2. Were any of the scales superior over the other(s) for clinical use? Methods A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for clinical trials published before November 2017, on the comparison of the pain scores in adults and preferences of the specific patient groups. A literature search via electronic databases was carried out for the last fifteen years on English Language papers. The search terms initially included pain rating scales, pain measurement, pain intensity, VAS, VRS, and NRS. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria. Results The initial data search yielded 872 potentially relevant studies; of these, 853 were excluded for some reason. The main reason for exclusion (33.7%) was that irrelevance to comparison of pain scales and scores, followed by pediatric studies (32.1%). Finally, 19 underwent full-text review, and were analysed for the study purposes. Studies were of moderate (n = 12, 63%) to low (n = 7, 37%) quality. Conclusions All three scales are valid, reliable and appropriate for use in clinical practice, although the VAS is more difficulties than the others. For general purposes the NRS has good sensitivity and generates data that can be analysed for audit purposes.

Machine learning approaches for predicting disposition of asthma and COPD exacerbations in the ED.

Abstract: Objective The prediction of emergency department (ED) disposition at triage remains challenging. Machine learning approaches may enhance prediction. We compared the performance of several machine learning approaches for predicting two clinical outcomes (critical care and hospitalization) among ED patients with asthma or COPD exacerbation. Methods Using the 2007–2015 National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, we identified adults with asthma or COPD exacerbation. In the training set (70% random sample), using routinely-available triage data as predictors (e.g., demographics, arrival mode, vital signs, chief complaint, comorbidities), we derived four machine learning-based models: Lasso regression, random forest, boosting, and deep neural network. In the test set (the remaining 30% of sample), we compared their prediction ability against traditional logistic regression with Emergency Severity Index (ESI, reference model). Results Of 3206 eligible ED visits, corresponding to weighted estimates of 13.9 million visits, 4% had critical care outcome and 26% had hospitalization outcome. For the critical care prediction, the best performing approach– boosting – achieved the highest discriminative ability (C-statistics 0.80 vs. 0.68), reclassification improvement (net reclassification improvement [NRI] 53%, P = 0.002), and sensitivity (0.79 vs. 0.53) over the reference model. For the hospitalization prediction, random forest provided the highest discriminative ability (C-statistics 0.83 vs. 0.64) reclassification improvement (NRI 92%, P Conclusions Based on nationally-representative ED data, machine learning approaches improved the ability to predict disposition of patients with asthma or COPD exacerbation.

Circulating lncRNA NEAT1 correlates with increased risk, elevated severity and unfavorable prognosis in sepsis patients

Abstract: Objective To investigate the correlation of circulating long non-coding RNA nuclear-enriched abundant transcript 1 (lncRNA NEAT1) expression with disease risk, severity, prognosis and inflammatory cytokine levels in sepsis patients. Methods 152 sepsis patients and 150 health controls (HCs) were enrolled in this study. Plasma and serum samples were obtained from sepsis patients and HCs, and lncRNA NEAT1 expression in plasma was determined by quantitative polymerase chain reaction, while levels of inflammatory cytokines in serum were detected by enzyme linked immune sorbent assay. Results LncRNA NEAT1 expression was remarkably higher in sepsis patients than in HCs (P Conclusion Circulating lncRNA NEAT1 correlates with increased disease risk, elevated severity and unfavorable prognosis as well as higher expression of pro-inflammatory cytokines in sepsis patients.

Clinical pharmacy services in the emergency department.

Abstract: The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.

National characteristics of Emergency Department visits by patients with cancer in the United States

Abstract: Purpose The Emergency Department (ED) is an important venue for the care of patients with cancer. We sought to describe the national characteristics of ED visits by patients with cancer in the United States. Methods We performed an analysis of 2012–2014 ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). We included adult (age ≥ 18 years) ED patients, stratified by history of cancer. Using the NHAMCS survey design and weighting variables, we estimated the annual number of adult ED visits by patients with cancer. We compared demographics, clinical characteristics, ED resource utilization, and disposition of cancer vs. non-cancer patients. Results There were an estimated 104,836,398 annual ED visits. Patients with cancer accounted for an estimated 3,879,665 (95% CI: 3,416,435–4,342,895) annual ED visits. Compared with other ED patients, those with cancer were older (mean 64.8 vs. 45.4 years), more likely to arrive by Emergency Medical Services (28.0 vs. 16.9%), and experienced longer lengths of ED stay (mean 4.9 vs. 3.8 h). Over 65% of ED patients with cancer underwent radiologic imaging. Patients with cancer almost twice as likely to undergo CT scanning; four times more likely to present with sepsis; twice as likely to present with thrombosis, and three times more likely to be admitted to the hospital than non-cancer patients. Conclusions Patients with cancer comprise nearly 4 million ED visits annually. The findings highlight the important role of the ED in cancer care and need for addressing acute care conditions in patients with cancer.

Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan.

Abstract: Background Military hospital healthcare providers treated children during the recent conflicts in Afghanistan and Iraq. Compared to adults, pediatric patients present unique challenges during trauma resuscitations and have notably been discussed in few research reports. We seek to describe ED interventions performed on pediatric trauma patients in Iraq and Afghanistan. Methods We queried the Department of Defense Trauma Registry (DODTR) for all pediatric patients in Iraq and Afghanistan from January 2007 to January 2016. Subjects were grouped based on Centers for Disease Control age categories. We used descriptive statistics. Results During this period, there were 3388 pediatric encounters that arrived at the ED with signs of life or on-going interventions. Most subjects were male (77.2%), located in Afghanistan (67.9%), injured by explosive (43.2%), and admitted to an intensive care unit (57.8%). Most of those arriving to the ED alive or with on-going interventions survived to hospital discharge (91.6%). The most frequently encountered age group was 5–9 years (33.3%) followed by 10–14 years (31.5%). The most common interventions were vascular access (86.6%), fluid administration (85.0%), and external warming (44.6%). Intubation was the most frequent airway intervention (18.2%). Packed red blood cells were the most frequently administered blood product (33.8% of subjects). Conclusions Pediatric subjects accounted for a notable portion of care delivered in theater emergency departments during the study period. Vascular access and fluid administration were the most frequently performed interventions. Pediatric-specific training is needed as a part of deployment medicine operations.

Echocardiography in cardiac arrest: An emergency medicine review

Abstract: Introduction Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising. Objectives This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support. Discussion Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts. Conclusions POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.

Coronary artery bypass graft surgery complications: A review for emergency clinicians.

Abstract: Introduction Coronary artery bypass graft (CABG) surgery remains a high-risk procedure, and many patients require emergency department (ED) management for complications after surgery. Objective This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post-CABG surgery complications. Discussion While there has been a recent decline in all cardiac revascularization procedures, there remains over 200,000 CABG surgeries performed in the United States annually, with up to 14% of these patients presenting to the ED within 30 days of discharge with post-operative complications. Risk factors for perioperative mortality and morbidity after CABG surgery can be divided into three categories: patient characteristics, clinician characteristics, and postoperative factors. Emergency physicians will be faced with several postoperative complications, including sternal wound infections, pneumonia, thromboembolic phenomena, graft failure, atrial fibrillation, pulmonary hypertension, pericardial effusion, strokes, renal injury, gastrointestinal insults, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary surgical team is needed, which improves patient outcomes. This review provides several guiding principles for management of acute complications. Understanding these complications and an approach to the management of hemodynamic instability is essential to optimizing patient care. Conclusions Postoperative complications of CABG surgery can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Early surgical consultation is imperative, as is optimizing the patient's hemodynamics, including preload, heart rate, cardiac rhythm, contractility, and afterload.

The influence of crowding on clinical practice in the emergency department.

Abstract: Background This study aimed to clarify the association between the crowding and clinical practice in the emergency department (ED). Methods This 1-year retrospective cohort study conducted in two EDs in Taiwan included 70,222 adult non-trauma visits during the day shift between July 1, 2011, and June 30, 2012. The ED occupancy status, determined by the number of patients staying during their time of visit, was used to measure crowding, grouped into four quartiles, and analyzed in reference to the clinical practice. The clinical practices included decision-making time, patient length of stay, patient disposition, and use of laboratory examinations and computed tomography (CT). Result The four quartiles of occupancy statuses determined by the number of patients staying during their time of visit were 62. Comparing > 62 and Conclusion Overcrowding in the ED might increase physicians' decision-making time and patients' length of stay, and more patients could be admitted to observation units or an inpatient department. The use of CT and laboratory examinations would also increase. All of these could lead more patients to stay in the ED.

Randomized controlled trial of internal and external targeted temperature management methods in post- cardiac arrest patients.

Abstract: Background Targeted temperature management post-cardiac arrest is currently implemented using various methods, broadly categorized as internal and external. This study aimed to evaluate survival-to-hospital discharge and neurological outcomes (Glasgow-Pittsburgh Score) of post-cardiac arrest patients undergoing internal cooling verses external cooling. Methodology A randomized controlled trial of post-resuscitation cardiac arrest patients was conducted from October 2008–September 2014. Patients were randomized to either internal or external cooling methods. Historical controls were selected matched by age and gender. Analysis using SPSS version 21.0 presented descriptive statistics and frequencies while univariate logistic regression was done using R 3.1.3. Results 23 patients were randomized to internal cooling and 22 patients to external cooling and 42 matched controls were selected. No significant difference was seen between internal and external cooling in terms of survival, neurological outcomes and complications. However in the internal cooling arm, there was lower risk of developing overcooling ( p = 0.01) and rebound hyperthermia ( p = 0.02). Compared to normothermia, internal cooling had higher survival (OR = 3.36, 95% CI = (1.130, 10.412), and lower risk of developing cardiac arrhythmias (OR = 0.18, 95% CI = (0.04, 0.63)). Subgroup analysis showed those with cardiac cause of arrest (OR = 4.29, 95% CI = (1.26, 15.80)) and sustained ROSC (OR = 5.50, 95% CI = (1.64, 20.39)) had better survival with internal cooling compared to normothermia. Cooling curves showed tighter temperature control for internal compared to external cooling. Conclusion Internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival-to-hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

Abstract: Introduction In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. Methods A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using “trauma”, “trauma center,” or “trauma system”, combined with “triage”, “undertriage,” or “overtriage”, as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. Results A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. Conclusion In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients.

Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival.

Abstract: Introduction Establishing peripheral intravenous (IV) access is a vital step in providing emergency care. Ten to 30% of Emergency Department (ED) patients have difficult vascular access (DVA). Even after cannulation, early failure of US-guided IV catheters is a common complication. The primary goal of this study was to compare survival of a standard long IV catheter to a longer extended dwell catheter. Methods This study was a prospective, randomized comparative evaluation of catheter longevity. Two catheters were used in the comparison: [1] a standard long IV catheter, the 4.78 cm 20 gauge Becton Dickinson (BD); and [2] a 6 cm 3 French (19.5 gauge) Access Scientific POWERWAND™ extended dwell catheter (EDC). Adult DVA patients in the ED with vein depths of 1.20 cm–1.60 cm and expected hospital admissions of at least 24 h were recruited. Results 120 patients were enrolled. Ultimately, 70 patients were included in the survival analysis, with 33 patients in the EDC group and 37 patients in the standard long IV group. EDC catheters had lower rates of failure (p = 0.0016). Time to median catheter survival was 4.04 days for EDC catheters versus 1.25 days for the standard long IV catheter. Multivariate survival analysis also showed a significant survival benefit for the EDC catheter (p = 0.0360). Conclusion A longer extended dwell catheter represents a viable and favorable alternative to the standard longer IVs used for US-guided cannulation of veins >1.20 cm in depth. These catheters have significantly improved survival rates with similar insertion success characteristics.

The evaluation and management of urolithiasis in the ED: A review of the literature.

Abstract: Background Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage. Objective With the new evidence concerning the evaluation and treatment of urolithiasis, this review summarizes current literature regarding the ED management of urolithiasis. Discussion Urolithiasis occurs primarily through supersaturation of urine and commonly presents with flank pain, hematuria, and nausea/vomiting. History, examination, and assessment with several laboratory tests are cornerstones of evaluation. Urinalysis is not diagnostic, but it may be used in association with other assessments. Risk assessment tools and advanced imaging can assist with diagnosis. Computed tomography (CT) is often considered the gold standard. Newer low-dose CT imaging may reduce radiation. Recent studies support ultrasound as an alternate diagnostic modality, especially in pediatric and pregnant patients. Nonsteroidal anti-inflammatory drugs remain first-line therapy, with opioids or intravenous lidocaine reserved for refractory pain. Tamsulosin can increase passage in larger stones but has not demonstrated benefit in smaller stones. Nifedipine and intravenous fluids are not recommended to facilitate passage. Surgical intervention is based upon stone size, duration, and modifying factors. Patients who are discharged should be advised on dietary changes. Conclusion Urolithiasis is a common disease increasing in prevalence with the potential for significant morbidity. Focused evaluation with history, examination, and testing is important in diagnosis and management. Understanding the clinical features, risk assessment tools, imaging options, and treatment options can assist emergency physicians in the management of urolithiasis.

Biphasic anaphylaxis: A review of the literature and implications for emergency management.

Abstract: Background The biphasic reaction is a feared complication of anaphylaxis management in the emergency department (ED). The traditional recommended ED observation time is 4–6 h after complete resolution of symptoms for every anaphylaxis patient. However, there has been great controversy regarding whether this standard of care is evidence-based. Methods Articles were selected using a PubMed, MEDLINE search for the keywords “biphasic anaphylaxis”, yielding 155 articles. Articles were filtered by English language, and the keyword biphasic in the title. Case reports and case series were excluded, narrowing to 33 articles. Then, articles were filtered by relevance to the ED setting, and studies conducted in outpatient clinic settings were excluded, narrowing the search to 16 articles. All remaining articles were reviewed and findings were discussed. Results The reported mean time to onset between the resolution of initial anaphylaxis and biphasic reaction ranges widely by study from 1 to 72 h with the majority of studies reporting the mean time to onset >8 h. A delay between anaphylaxis symptom onset and administration of epinephrine of 60–190 min was reported to correlate with biphasic anaphylaxis in three studies. Anaphylaxis requiring >1 dose of epinephrine to achieve symptom resolution was also reported to correlate with biphasic reactions in two studies. No definitive conclusions about the role of corticosteroids in preventing biphasic reactions can be made at this time however; a couple small studies have shown that they may decrease the incidence of biphasic reactions. Additional risk factors correlated with biphasic reaction vary widely between studies and the generalizability of these risk factors is questionable. Conclusions There is a need for further research to identify true risk factors associated with biphasic anaphylaxis and to clearly define the role of corticosteroids in biphasic reactions. However, given the low incidence and rare mortality of biphasic reactions, patients who receive epinephrine within one hour of symptom onset and who respond to epinephrine with rapid and complete symptom resolution can probably be discharged from the ED with careful return precautions and education without the need for prolonged observation.

Methamphetamine use and heart failure: Prevalence, risk factors, and predictors.

Abstract: Objectives To compare methamphetamine users who develop heart failure to those who do not and determine predictors. Methods Patients presenting over a two-year period testing positive for methamphetamine on their toxicology screen were included. Demographics, vital signs, echocardiography and labs were compared between patients with normal versus abnormal B-type natriuretic peptide (BNP). Results 4407 were positive for methamphetamine, 714 were screened for heart failure, and 450 (63%) had abnormal BNP. The prevalence of abnormal BNP in methamphetamine-positive patients was 10.2% versus 6.7% for those who were negative or not tested. For methamphetamine-positive patients, there was a tendency for higher age and male gender with abnormal BNP. A higher proportion of Whites and former smokers had abnormal BNP and higher heart and respiratory rates. Echocardiography revealed disparate proportions for normal left ventricular ejection fraction (LVEF) and severe dysfunction (LVEF Conclusion Methamphetamine-positive patients have a significantly higher prevalence of heart failure than the general emergency department population who are methamphetamine-negative or not tested. The methamphetamine-positive subgroup who develop heart failure tend to be male, older, White, former smokers, and have higher creatinine, heart and respiratory rates. This subgroup also has greater biventricular dysfunction, dimensions, and higher pulmonary arterial pressures.

Factors associated with imaging overuse in the emergency department: A systematic review.

Abstract: Background Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED. Methods We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED. Results Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging. Conclusions The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Risk factors for early return visits to the emergency department in patients with urinary tract infection.

Abstract: Background Optimal management of urinary tract infections (UTIs) in the emergency department (ED) is challenging due to high patient turnover, decreased continuity of care, and treatment decisions made in the absence of microbiologic data. We sought to identify risk factors for return visits in ED patients treated for UTI. Methods A random sample of 350 adult ED patients with UTI by ICD 9/10 codes was selected for review. Relevant data was extracted from medical charts and compared between patients with and without ED return visits within 30 days (ERVs). Results We identified 51 patients (15%) with 59 ERVs, of whom 6% returned within 72 h. Nearly half of ERVs (47%) were UTI-related and 33% of ERV patients required hospitalization. ERVs were significantly more likely ( P 100; and bacteremia. Escherichia coli was the most common uropathogen (70%) and susceptibility rates to most oral antibiotics were below 80% in both groups except nitrofurantoin (99% susceptible). Cephalexin was the most frequently prescribed antibiotic (51% vs. 44%; P = 0.32). Cephalexin bug-drug mismatches were more common in ERV patients (41% vs. 15%; P = 0.02). Culture follow-up occurred less frequently in ERV patients (75% vs. 100%; P Conclusions ERV in UTI patients may be minimized by using ED-source specific antibiogram data to guide empiric treatment decisions and by targeting at-risk patients for post-discharge follow-up.

Grit, anxiety, and stress in emergency physicians.

Abstract: Introduction The personality traits of emergency physicians are infrequently studied, though interest in physician wellness is increasing. The objective of this study is to acquire pilot data about the amount of grit, anxiety, and stress in emergency physicians using established psychological survey instruments, and to examine their associations of each of these traits with each other. Methods Thirty-six emergency medicine resident and attending physicians from an urban academic medical center consented for enrollment. Participants were administered the Duckworth 12-point Grit Scale, the State-Trait Anxiety Inventory (STAI), and the Perceived Stress Scale (PSS), which measure grit, anxiousness, and perceived stress, respectively. These are the gold standard psychological instruments for each of their areas. We analyzed the results with descriptive statistics, Spearman correlations, and linear regression. Results Nineteen residents and 17 attending physicians completed the surveys during the first quarter of a new academic year. The mean grit score was 3.7 (95% CI 3.5–3.8, SD: 0.56), the mean trait-anxiety score was 32.61 (95% CI 30.15–35.07, SD: 7.26), and the mean PSS score was 12.28 (95% CI 10.58–13.97, SD: 4.99). Only trait-anxiety and perceived stress were significantly correlated (Spearman's rho: 0.70, p Conclusions In this pilot study at a single institution, emergency physicians demonstrated a range of grit, trait-anxiety, and perceived stress. Trait-anxiety and stress were strongly associated, and individuals who were more anxious reported more stress. Levels of grit were not associated with trait-anxiety. These psychological concepts should be studied further as they relate to the function and health of emergency medicine providers.

Coagulopathy as a predictor of mortality after penetrating traumatic brain injury.

Abstract: Study hypothesis Traumatic brain injury (TBI) is a leading cause of mortality with penetrating TBI (p-TBI) patients having worse outcomes. These patients are more likely to be coagulopathic than blunt TBI (b-TBI) patients, thus we hypothesize that coagulopathy would be an early predictor of mortality. Methods We identified highest-level trauma activation patients who underwent an admission head CT and had ICU admission orders from August 2009–May 2013, excluding those with polytrauma and anticoagulant use. Rapid thrombelastography (rTEG) was obtained after emergency department (ED) arrival and coagulopathy was defined as follows: ACT ≥ 128 s, KT ≥ 2.5 s, angle ≤ 56°, MA ≤ 55 mm, LY-30 ≥ 3.0% or platelet count ≤ 150,000/μL. Regression modeling was used to assess the association of coagulopathy on mortality. Results 1086 patients with head CT scans performed and ICU admission orders were reviewed. After exclusion criteria were met, 347 patients with isolated TBI were analyzed-99 (29%) with p-TBI and 248 (71%) with b-TBI. Patients with p-TBI had a higher mortality (41% vs. 10%, p p p -value = 0.012). Conclusions This study demonstrates that p-TBI patients with significant coagulopathy have a poor prognosis. Coagulopathy, in conjunction with other factors, can be used to earlier identify p-TBI patients with worse outcomes and represents a possible area for intervention.

Scoring systems used to predict mortality in patients with acute upper gastrointestinal bleeding in the ED

Abstract: Objective Acute upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition that requires rapid assessment in the emergency department (ED). We aimed to compare the performance of the AIMS65, Glasgow-Blatchford (Blatchford), preendoscopic Rockall (pre-Rockall), and preendoscopic Baylor bleeding (pre-Baylor) scores in predicting 30-day mortality in patients with acute UGIB in the ED setting. Methods Consecutive patients with acute UGIB who were admitted to the ED ward during 2012–2016 were retrospectively recruited. Data were retrieved from the admission list of the ED using international classification of disease codes via computer registration. The predictive accuracy of these four scores was compared using the area under the receiver operating characteristic curve (AUC) method. Results Among the 395 patients included during the study period, the total 30-day mortality rate was 10.4% (41/395). The AIMS65 and Glasgow-Blatchford scores performed better with an AUC of 0.907 (95% confidence interval (CI), 0.852–0.963; P P P P > 0.05). Conclusion In patients with acute UGIB in the ED, the AIMS65 and Glasgow–Blatchford scores are clinically more useful for predicting 30-day mortality than the preendoscopic Rockall and preendoscopic Baylor scores. The AIMS65 score might be more ideal for risk stratification in the ED setting.

Association of clinician burnout and perceived clinician-patient communication☆☆☆

Abstract: Patient satisfaction in the emergency department (ED) has become increasingly important over the past decade [1]. Past work has found patient satisfaction associated with increased care compliance, [2,3] decreased litigation risk [4] and fiscal improvement for institutions [5]. In the context of this growing emphasis on patient satisfaction, a large body of work has attempted to identify ED stay factors associated with satisfaction. Previous work has examined the impact of environmental variables such as crowding [6] wait time [7] and analgesic use [8]. Another aspect of a patient's ED stay that may play a significant role in patient satisfaction is clinician-patient communication. Strong clinicianpatient communication has been associated with multiple positive patient outcomes from medication compliance, [9] reduced stress, [10] and decreased litigation [11].While pastwork has noted that overall clinician-patient communication is associated with patient satisfaction, [11-13] less work has focused on individual provider level factors. In particular, clinician “burnout” may impact perceptions of clinician-patient communication. Burnout, defined by emotional exhaustion, physical fatigue, and cognitive weariness, [14] results from high and sustained levels of stress and is associatedwith feelings of irritability, fatigue, and cynicism [15]. In a sample of physicians across specialties adjusted for age, sex, hours worked, and years of practice, emergency physicians were at greatest risk for burnout (odds ratio [OR], 3.18; P b 0.001), with nearly 70% reporting burnout (the mean across specialties was under 50%) [16]. The negative impact of burnout on clinicians is broad including increased risk for depression, [17] anxiety, [18] and substance abuse [19]. However, clinician burnoutmay also affect patient care outcomes. Previous work has found clinician burnout associated with job absenteeism and increased medical errors [12]. The goal of this study was to build on this existing work and evaluate the association between clinician burnout and perceived clinician-patient communication in ED patients. We conducted a prospective observational study of 63 emergency staff (nurses and physicians) and 167 patients evaluated for potential acute coronary syndrome (ACS). We limited our patient cohort to potential ACS in order to attempt to account for variations in clinician-patient communication secondary tomedical illness. All patients receiving care in the ED and evaluated for ACSwere eligible. Clinician participants

Infectious endocarditis: An update for emergency clinicians

Abstract: Introduction Infectious endocarditis (IE) is a potentially deadly disease without therapy and can cause a wide number of findings and symptoms, often resembling a flu-like illness, which makes diagnosis difficult. Objective This narrative review evaluates the presentation, evaluation, and management of infective endocarditis in the emergency department, based on the most current literature. Discussion IE is due to infection of the endocardial surface, most commonly cardiac valves. Major risk factors include prior endocarditis (the most common risk factor), structural heart damage, IV drug use (IVDU), poor immune function (vasculitis, HIV, diabetes, malignancy), nosocomial (surgical hardware placement, poor surgical technique, hematoma development), and poor oral hygiene, and a wide variety of organisms can cause IE. Patients typically present with flu-like illness. Though fever and murmur occur in the majority of cases, they may not be present at the time of initial presentation. Other findings such as Roth spots, Janeway lesions, Osler nodes, etc. are not common. An important component is consideration of risk factors. A patient with IVDU (past or current use) and fever should trigger consideration of IE. Other keys are multiple sites of infection, poor dentition, and abnormal culture results with atypical organisms. If endocarditis is likely based on history and examination, admission for further evaluation is recommended. Blood cultures and echocardiogram are key diagnostic tests. Conclusions Emergency physicians should consider IE in the patient with flu-like symptoms and risk factors. Appropriate evaluation and management can significantly reduce disease morbidity and mortality.

High dose insulin for beta-blocker and calcium channel-blocker poisoning

Abstract: Background/objectives High dose insulin (HDI) is a standard therapy for beta-blocker (BB) and calcium channel-blocker (CCB) poisoning, however human case experience is rare. Our poison center routinely recommends HDI for shock from BBs or CCBs started at 1 U/kg/h and titrated to 10 U/kg/h. The study objective was to describe clinical characteristics and adverse events associated with HDI. Methods This was a structured chart review of patients receiving HDI for BB or CCB poisoning with HDI defined as insulin infusion of ≥0.5 U/kg/h. Results In total 199 patients met final inclusion criteria. Median age was 48 years (range 14–89); 50% were male. Eighty-eight patients (44%) were poisoned by BBs, 66 (33%) by CCBs, and 45 (23%) by both. Median nadir pulse was 54 beats/min (range 12–121); median nadir systolic blood pressure was 70 mm Hg (range, 30–167). Forty-one patients (21%) experienced cardiac arrest; 31 (16%) died. Median insulin bolus was 1 U/kg (range, 0.5–10). Median starting insulin infusion was 1 U/kg/h (range 0.22–10); median peak infusion was 8 U/kg/h (range 0.5–18). Hypokalemia occurred in 29% of patients. Hypoglycemia occurred in 31% of patients; 50% (29/50) experienced hypoglycemia when dextrose infusion concentration ≤10%, and 30% (31/105) experienced hypoglycemia when dextrose infusion concentration ≥20%. Conclusions HDI, initiated by emergency physicians in consultation with a poison center, was feasible and safe in this large series. Metabolic abnormalities were common, highlighting the need for close monitoring. Hypoglycemia was more common when less concentrated dextrose maintenance infusions were utilized.

Physical therapy in the emergency department: A new opportunity for collaborative care.

Abstract: Emergency department-initiated physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait disturbances. Patients receiving ED PT benefit from the physical therapist's expertise in musculoskeletal and vestibular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services favorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing programs around the country.

Inter-scanner variability in Hounsfield unit measured by CT of the brain and effect on gray-to-white matter ratio.

Abstract: Purpose: The density ratio of gray matter (GM) to white matter (WM) on brain computed tomography (CT) (gray-to-white matter ratio, GWR) helps predict the prognosis of comatose patients after cardiac arrest. However, Hounsfield units (HU) are not an absolute value and can change based on imaging parameters and CT scanners. We compared the density of brain GM and WM and the GWR by using images scanned with different types of CT machines. Method: 102 patients with normal readings who were scanned using three types of CT scanners were included in the study. HU were measured at the basal ganglia level by two observers with circular regions of interest. Result: The difference in GM was 0.98–10.30 HU and WM was 1.05–7.55 HU. The mean value of measured HU and GWR were different for each CT group. The ANOVA test showed significant difference all variables. The post hoc test for GWR, which was used to compare the differences between each scanner, was statistically significant. Interclass correlation coefficients of measured GM and WM between the two observers were very high (Cronbach's α = 0.995 and 0.990, respectively) and GWR was showed good confidence level (0.798). Conclusion: In this study, the HU values of GM and WM in the normal adult brain differed up to 23% among scanners. Unfortunately, the GWR may not compensate for the HU difference between GM and WM occurring between scanners. Therefore, rather than applying consistent GWR cut-offs, the protocol or manufacturer differences between imaging scanners should be considered.

Battlefield acupuncture to treat low back pain in the emergency department.

Abstract: Introduction Battlefield acupuncture (BFA) is an ear acupuncture protocol used by the military for immediate pain relief. This is a pilot feasibility study of BFA as a treatment for acute low back pain (LBP) in the emergency department (ED). Methods Thirty acute LBP patients that presented to ED were randomized to standard care plus BFA or standard care alone. In the BFA group, outcomes were assessed at the time of randomization, 5 min after intervention, and again within 1 h after intervention. In the standard care group outcomes were assessed at the time of randomization and again an hour later. Primary outcomes included post-intervention LBP on a 10-point numeric pain rating scale (NRS) and the timed get-up-and-go test (GUGT). t-Test and chi squared tests were used to compare differences between groups demographics to evaluate randomization, and Analysis of Covariance (ANCOVA) was used to assess differences in primary/secondary outcomes. Results We randomized 15 patients to BFA plus standard care, and 15 patients to standard care alone. Demographics were similar between groups. Post-intervention LBP NRS was significantly lower in the BFA group compared with the standard care group (5.2 vs. 6.9, ANCOVA p = 0.04). GUGT was similar between groups (21.3 s vs. 19.0 s, ANCOVA p = 0.327). No adverse events from acupuncture were reported. Discussion This pilot study demonstrates that BFA is feasible as a therapy for LBP in the ED. Furthermore, our data suggest that BFA may be efficacious to improve LBP symptoms, and thus further efficacy studies are warranted. ( Clinicaltrials.gov registration number NCT02399969 ).

A mathematical model for efficient emergency transportation in a disaster situation.

Abstract: This work focuses on a real-life patient transportation problem derived from emergency medical services (EMS), whereby providing ambulatory service for emergency requests during disaster situations. Transportation of patients in congested traffic compounds already time sensitive treatment. An urgent situation is defined as individuals with major or minor injuries requiring EMS assistance simultaneously. Patients are either (1) slightly injured and treated on site or (2) are seriously injured and require transfer to points of care (PoCs). This paper will discuss enhancing the response-time of EMS providers by improving the ambulance routing problem (ARP). A genetic based algorithm is proposed to efficiently guide the ARP while simultaneously solving two scenarios.

Efficacy of prehospital administration of tranexamic acid in trauma patients: A meta-analysis of the randomized controlled trials

Abstract: Objective Antifibrinolytic agent tranexamic acid (TXA) has a potential clinical benefit for in-hospital patients with severe bleeding but its effectiveness in pre-hospital settings remains unclear. We conducted a systematic review and meta-analysis to evaluate whether pre-hospital administration of TXA compared to placebo improve patients' outcomes? Methods PubMed, MEDLINE, Cochrane Library, WHO International Clinical Trials Registry Platform, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, clinicaltrials.gov and Google scholar databases were searched for a retrospective, prospective and randomized (RCT) or quasi-RCT studies that assessed the effect of prehospital administration of TXA versus placebo on the outcomes of trauma patients with significant hemorrhage. The main outcomes of interest were 24 hour 30-day mortality and in-hospital thromboembolic complications. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for the analysis, when appropriate. Results Out of 92 references identified through the search, two analytical studies met the inclusion criteria. The effect of TXA on 24-hour mortality had a pooled odds ratio (OR) of 0.49 (95% CI 0.28–0.85), 30-day mortality OR of 0.86 (95% CI, 0.56–1.32), and thromboembolic events OR of 0.74 (95% CI, 0.27–2.07). Conclusion Prehospital TXA appears to reduce early mortality in trauma patients. The pooled analysis also shows a trend toward lower 30-day mortality and reduced risk of thromboembolic events. Additional randomized controlled clinical trials are needed to determine the significance of these trends.