Impact of Implementation of a New Weapons Screening at an Urban Emergency Department

BACKGROUND

Violence in the emergency department (ED) setting is well documented in medical literature. Weapons can be used to cause significant injury or mortality, although there is a paucity of literature on weapons and weapons screening in the ED.

OBJECTIVES

The purpose of this study was to assess the impact of initiating a weapons screening process on the identification and removal of weapons.

METHODS

Multiple aspects of a weapons screening program were evaluated at 2 and 6 months prior to and after a weapons screening protocol was initiated at an urban ED. In the Pre-Screen periods, only patients primarily seeking care for mental health were screened prior to entry. In the Post-Screen periods, all patients and visitors were screened with walk-through magnetometers or wand metal detectors, and additional screening checks were initiated. The number of individuals screened and numbers of weapons found were measured. Descriptive statistics comparing Pre- and Post-Screen periods were performed.

RESULTS

Prior to the new screening process, 511 and 1701 patients primarily seeking care for mental health were screened, with 15 and 103 weapons confiscated at 2 and 6 months, respectively. After the screening process was initiated, 13,149 and 43,321 ED patients and visitors were screened, with 194 and 567 weapons confiscated at 2 and 6 months, respectively. Persons screened increased by 25-fold at both 2 and 6 months after implementing the screening process. Weapons confiscated increased approximately 13-fold and sixfold at the respective 2- and 6-month Pre- and Post-Screen periods, respectively.

CONCLUSION

Implementation of weapons screening significantly increased the number of weapons identified and confiscated prior to entry in the ED by patients and visitors.

The Influence of Body Mass Index on Clinical Interpretation of Established and Novel Biomarkers in Acute Heart Failure

BACKGROUND

Body mass index (BMI) is a known confounder for natriuretic peptides, but its influence on other biomarkers is less well described. We investigated whether BMI interacts with biomarkers' association with prognosis in patients with acute heart failure (AHF).

METHODS AND RESULTS

B-type natriuretic peptide (BNP), high-sensitivity cardiac troponin I (hs-cTnI), galectin-3, serum neutrophil gelatinase-associated lipocalin (sNGAL), and urine NGAL were measured serially in patients with AHF during hospitalization in the AKINESIS (Acute Kidney Injury Neutrophil gelatinase-associated lipocalin Evaluation of Symptomatic Heart Failure) study. Cox regression analysis was used to determine the association of biomarkers and their interaction with BMI for 30-day, 90-day and 1-year composite outcomes of death or HF readmission. Among 866 patients, 21.2%, 29.7% and 46.8% had normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2) or obese (≥ 30 kg/m2) BMIs on admission, respectively. Admission values of BNP and hs-cTnI were negatively associated with BMI, whereas galectin-3 and sNGAL were positively associated with BMI. Admission BNP and hs-cTnI levels were associated with the composite outcome within 30 days, 90 days and 1 year. Only BNP had a significant interaction with BMI. When BNP was analyzed by BMI category, its association with the composite outcome attenuated at higher BMIs and was no longer significant in obese individuals. Findings were similar when evaluated by the last-measured biomarkers and BMIs.

CONCLUSIONS

In patients with AHF, only BNP had a significant interaction with BMI for the outcomes, with its association attenuating as BMI increased; hs-cTnI was prognostic, regardless of BMI.

4th Generation HIV screening in the emergency department: net profit or loss for hospitals?

ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.

Physiological Effects of a Spit Restraint Device Saturated With Artificial Saliva

BACKGROUND

Spit restraint devices, also referred to as spit hoods, spit masks, or spit socks, are used by law enforcement and medical personnel to minimize transmission of communicable disease from bodily fluids from agitated individuals. Several lawsuits have implicated spit restraint devices as contributing to the death of individuals who are physically restrained by means of asphyxiation due to saturation of the mesh restraint device with saliva.

OBJECTIVES

This study aims to evaluate whether a saturated spit restraint device has any clinically significant effects on the ventilatory or circulatory parameters of healthy adult subjects.

METHODS

Subjects wore a spit restraint device dampened with 0.5% carboxymethylcellulose, an artificial saliva. Baseline vitals were taken, and a wet spit restraint device was then placed over the subject's head, and repeat measurements were taken at 10, 20, 30, and 45 min. A second spit restraint device was placed 15 min after the first. Measurements at 10, 20, 30, and 45 min were compared with baseline using paired t-tests.

RESULTS

The mean age of 10 subjects was 33.8 years, and 50% were female. There was no significant difference between baseline and while wearing the spit sock for 10, 20, 30, and 45 min for the measured parameters including heart rate, oxygen saturation, end-tidal CO₂, respiratory rate, or blood pressure. No subject indicated respiratory distress or had to terminate the study.

CONCLUSIONS

In healthy adult subjects, there were no statistically or clinically significant differences in ventilatory or circulatory parameters while wearing the saturated spit restraint.

Galectin-3, Acute Kidney Injury and Myocardial Damage in Patients With Acute Heart Failure

BACKGROUND

Galectin-3, a biomarker of inflammation and fibrosis, can be associated with renal and myocardial damage and dysfunction in patients with acute heart failure (AHF).

METHODS AND RESULTS

We retrospectively analyzed 790 patients with AHF who were enrolled in the AKINESIS study. During hospitalization, patients with galectin-3 elevation (> 25.9 ng/mL) on admission more commonly had acute kidney injury (assessed by KDIGO criteria), renal tubular damage (peak urine neutrophil gelatinase-associated lipocalin [uNGAL] > 150 ng/dL) and myocardial injury (≥ 20% increase in the peak high-sensitivity cardiac troponin I [hs-cTnI] values compared to admission). They less commonly had ≥ 30% reduction in B-type natriuretic peptide from admission to last measured value. In multivariable linear regression analysis, galectin-3 was negatively associated with estimated glomerular filtration rate and positively associated with uNGAL and hs-cTnI. Higher galectin-3 was associated with renal replacement therapy, inotrope use and mortality during hospitalization. In univariable Cox regression analysis, higher galectin-3 was associated with increased risk for the composite of death or rehospitalization due to HF and death alone at 1 year. After multivariable adjustment, higher galectin-3 levels were associated only with death.

CONCLUSIONS

In patients with AHF, higher galectin-3 values were associated with renal dysfunction, renal tubular damage and myocardial injury, and they predicted worse outcomes.

Frequency and Outcomes of Cervical Spine Computed Tomography Imaging on Alcohol-Intoxicated Patients in the Emergency Department

BACKGROUND

Cervical spinal (c-spine) injuries range greatly in severity from minor ligamentous injuries to osteoligamentous instability with spinal cord injuries. Initial evaluation begins with stabilization as needed and immediate immobilization. Current practice as to whether the c-spine can be cleared clinically without radiographic evaluation is often guided by using the National Emergency X-Radiography Utilization Study Low-Risk Criteria and the Canadian C-Spine Rule. Under these clinical decision guidelines, stable trauma patients presenting with alcohol intoxication cannot have the c-spine cleared clinically and imaging should be "considered."

OBJECTIVE

This study aimed to assess the frequency of computed tomography (CT) c-spine scans ordered for patients presenting with alcohol intoxication to the emergency department (ED), the timing of the studies, and subsequently determine the proportion of which showed a clinically significant result that required intervention.

METHODS

In this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to two academic EDs were included. Overall demographic characteristics, time to order of CT imaging, radiology reads, and outcomes of patient visits were determined.

RESULTS

There were 8008 patient visits included in the study. Of these visits, 5 patients scanned in ≤3 h had acute findings on CT scan and no patients with a deferred timing of CT scan after patients metabolized had an acute finding on CT scan. No patients required operative management.

CONCLUSIONS

This study's results suggest that it is a safe clinical practice to defer CT imaging for patients presenting to the ED with alcohol intoxication and low suspicion for c-spine injury per history and examination.

Implications of worsening renal function before hospitalization for acute heart failure

AIMS

Kidney function changes dynamically during AHF treatment, but risk factors for and consequences of worsening renal function (WRF) at hospital admission are uncertain. We aimed to determine the significance of WRF at admission for acute heart failure (AHF).

METHODS AND RESULTS

We evaluated a subgroup of 406 patients from The Acute Kidney Injury Neutrophil gelatinase-associated lipocalin Evaluation of Symptomatic heart failure Study (AKINESIS) who had serum creatinine measurements available within 3 months before and at the time of admission. Admission WRF was primarily defined as a 0.3 mg/dL or 50% creatinine increase from preadmission. Alternative definitions evaluated were a ≥0.5 mg/dL creatinine increase, ≥25% glomerular filtration rate decrease, and an overall change in creatinine. Predictors of admission WRF were evaluated. Outcomes evaluated were length of hospitalization, a composite of adverse in-hospital events, and the composite of death or HF readmission at 30, 90, and 365 days. Biomarkers' prognostic ability for these outcomes were evaluated in patients with admission WRF. One-hundred six patients (26%) had admission WRF. These patients had features of more severe AHF with lower blood pressure, higher BUN, and lower serum sodium concentrations at admission. Higher BNP (odds ratio [OR] per doubling 1.16-1.28, 95% confidence interval [CI] 1.00-1.55) and lower diastolic blood pressure (OR 0.97-0.98, 95% CI 0.96-0.99) were associated with a higher odds for the three definitions of admission WRF. The primary WRF definition was not associated with a longer hospitalization, but alternative WRF definitions were (1.3 to 1.6 days longer, 95% CI 1.0-2.2). WRF across definitions was not associated with a higher odds of adverse in-hospital events or a higher risk of death or HF readmission. In the subset of patients with WRF, biomarkers were not prognostic for any outcome.

CONCLUSIONS

Admission WRF is common in AHF patients and is associated with an increased length of hospitalization, but not adverse in-hospital events, death, or HF readmission. Among those with admission WRF, biomarkers did not risk stratify for adverse events.

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BACKGROUND

Chemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED.

METHODS

A PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: "febrile neutropenia" OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review.

RESULTS

The search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%).

CONCLUSIONS

FN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.

Finding acute coronary syndrome with serial troponin testing for rapid assessment of cardiac ischemic symptoms (FAST-TRAC): a study protocol

Objective

To determine the utility of a highly sensitive troponin assay when utilized in the emergency department.

Methods

The FAST-TRAC study prospectively enrolled >1,500 emergency department patients with suspected acute coronary syndrome within 6 hours of symptom onset and 2 hours of emergency department presentation. It has several unique features that are not found in the majority of studies evaluating troponin. These include a very early presenting population in whom prospective data collection of risk score parameters and the physician’s clinical impression of the probability of acute coronary syndrome before any troponin data were available. Furthermore, two gold standard diagnostic definitions were determined by a pair of cardiologists reviewing two separate data sets; one that included all local troponin testing results and a second that excluded troponin testing so that diagnosis was based solely on clinical grounds. By this method, a statistically valid head-to-head comparison of contemporary and high sensitivity troponin testing is obtainable. Finally, because of a significant delay in sample processing, a unique ability to define the molecular stability of various troponin assays is possible.

Trial registration

ClinicalTrials.gov Identifier NCT00880802

Compression depth measured by accelerometer vs. outcome in patients with out-of-hospital cardiac arrest

BACKGROUND

Analyses of data recorded by monitor-defibrillators that measure CPR depth with different methods show significant relationships between the process and outcome of CPR. Our objective was to evaluate whether chest compression depth was significantly associated with outcome based on accelerometer-recordings obtained with monitor-defibrillators from a single manufacturer, and to assess whether an accelerometer-based analysis corroborated evidence-based practice guidelines on performance of CPR.

METHODS AND RESULTS

We included 5434 adult patients treated from seven US and Canadian cities between January 2007 and May 2015. These had mean (SD) age of 64.2 (17.2) years, mean compression depth of 45.9 (12.7) mm, ROSC sustained to ED arrival of 26%, and survival to hospital discharge of 8%. For survival to discharge, the adjusted odds ratios were 1.15 (95% CI, 0.86, 1.55) for cases within 2005 depth range (38-51 mm), and 1.17 (95% CI, 0.91, 1.50) for cases within 2010 depth range (>50 mm) compared to those with an average depth of <38 mm. The adjusted odds ratio of survival was 1.33 (95% CI, 1.01, 1.75) for cases within 2015 depth range (50 to 60 mm) for at least 60% of minutes.

CONCLUSIONS

This analysis of patients with OHCA demonstrated that increased chest compression depth measured by accelerometer is associated with better survival. It confirms that current evidence-based recommendations to compress within 50-60 mm are likely associated with greater survival than compressing to another depth.

Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position

BACKGROUND

The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise.

METHODS

Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences.

RESULTS

We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001).

CONCLUSIONS

In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.

Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor?

BACKGROUND

Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine.

METHODS

A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation.

RESULTS

The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review.

CONCLUSIONS

The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.

Relation of Decongestion and Time to Diuretics to Biomarker Changes and Outcomes in Acute Heart Failure

Prompt treatment may mitigate the adverse effects of congestion in the early phase of heart failure (HF) hospitalization, which may lead to improved outcomes. We analyzed 814 acute HF patients for the relationships between time to first intravenous loop diuretics, changes in biomarkers of congestion and multiorgan dysfunction, and 1-year composite end point of death or HF hospitalization. B-type natriuretic peptide (BNP), high sensitivity cardiac troponin I (hscTnI), urine and serum neutrophil gelatinase-associated lipocalin, and galectin 3 were measured at hospital admission, hospital day 1, 2, 3 and discharge. Time to diuretics was not correlated with the timing of decongestion defined as BNP decrease ≥ 30% compared with admission. Earlier BNP decreases but not time to diuretics were associated with earlier and greater decreases in hscTnI and urine neutrophil gelatinase-associated lipocalin, and lower incidence of the composite end point. After adjustment for confounders, only no BNP decrease at discharge was significantly associated with mortality but not the composite end point (p = 0.006 and p = 0.062, respectively). In conclusion, earlier time to decongestion but not the time to diuretics was associated with better biomarker trajectories. Residual congestion at discharge rather than the timing of decongestion predicted a worse prognosis.

Potential Utility of Cardiorenal Biomarkers for Prediction and Prognostication of Worsening Renal Function in Acute Heart Failure

BACKGROUND

Multiple different pathophysiologic processes can contribute to worsening renal function (WRF) in acute heart failure.

METHODS AND RESULTS

We retrospectively analyzed 787 patients with acute heart failure for the relationship between changes in serum creatinine and biomarkers including brain natriuretic peptide, high sensitivity cardiac troponin I, galectin 3, serum neutrophil gelatinase-associated lipocalin, and urine neutrophil gelatinase-associated lipocalin. WRF was defined as an increase of greater than or equal to 0.3 mg/dL or 50% in creatinine within first 5 days of hospitalization. WRF was observed in 25% of patients. Changes in biomarkers and creatinine were poorly correlated (r ≤ 0.21) and no biomarker predicted WRF better than creatinine. In the multivariable Cox analysis, brain natriuretic peptide and high sensitivity cardiac troponin I, but not WRF, were significantly associated with the 1-year composite of death or heart failure hospitalization. WRF with an increasing urine neutrophil gelatinase-associated lipocalin predicted an increased risk of heart failure hospitalization.

CONCLUSIONS

Biomarkers were not able to predict WRF better than creatinine. The 1-year outcomes were associated with biomarkers of cardiac stress and injury but not with WRF, whereas a kidney injury biomarker may prognosticate WRF for heart failure hospitalization.

Decongestion discriminates risk for one-year mortality in patients with improving renal function in acute heart failure

AIMS

Improving renal function (IRF) is paradoxically associated with worse outcomes in acute heart failure (AHF), but outcomes may differ based on response to decongestion. We explored if the relationship of IRF with mortality in hospitalized AHF patients differs based on successful decongestion.

METHODS AND RESULTS

We evaluated 760 AHF patients from AKINESIS for the relationship between IRF, change in B-type natriuretic peptide (BNP), and 1-year mortality. IRF was defined as a ≥20% increase in estimated glomerular filtration rate (eGFR) relative to admission. Adequate decongestion was defined as a ≥40% decrease in last measured BNP relative to admission. IRF occurred in 22% of patients who had a mean age of 69 years, 58% were men, 72% were white, and median admission eGFR was 49 mL/min/1.73 m² . IRF patients had more severe heart failure reflected by lower admission eGFR, higher blood urea nitrogen, lower systolic blood pressure, lower sodium, and higher use of inotropes. IRF patients had higher 1-year mortality (25%) than non-IRF patients (15%) (P < 0.01). However, this relationship differed by BNP trajectory (P-interaction = 0.03). When stratified by BNP change, non-IRF patients and IRF patients with decreasing BNP had lower 1-year mortality than either non-IRF and IRF patients without decreasing BNP. However, in multivariate analysis, IRF was not associated with mortality [adjusted hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.7-1.5] while BNP was (adjusted HR 0.5, 95% CI 0.3-0.7). When IRF was evaluated as transiently occurring or persisting at discharge, again only BNP change was significantly associated with mortality.

CONCLUSION

Improving renal function is associated with mortality in AHF but not independent of other variables and congestion status. Achieving adequate decongestion, as reflected by lower BNP, in AHF is more strongly associated with mortality than IRF.

Telemetry Bed Usage for Patients with Low-Risk Chest Pain: An Updated Review of the Literature for the Clinician

BACKGROUND

Telemetry monitoring in patients with low-risk chest pain continues to be highly used despite a 2011 literature review and recommendations by the Clinical Practice Committee (CPC) of the American Academy of Emergency Medicine that did not find quality data to support its use.

OBJECTIVE

To update the medical literature review on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians.

METHODS

A PubMed literature search was performed for systematic reviews in English relevant to low-risk chest pain between 2011 and 2019 and then expanded to all citations by removing the systematic review criteria. Studies identified then underwent a structured review from which results could be evaluated in the context of the associated 2011 literature review and CPC recommendations.

RESULTS

The initial search yielded 2 potentially relevant studies, although none directly addressed telemetry. The expanded search resulted in 76 abstracts that were screened. Two addressed telemetry, including the last CPC statement, which were reviewed and recommendations given.

CONCLUSIONS

No further quality data were identified to support the use of telemetry monitoring in patients with low-risk chest pains. Telemetry monitoring is unlikely to benefit patients with low-risk chest pain with a low-risk HEART Score.

How Should Native Crotalid Envenomation Be Managed in the Emergency Department?

BACKGROUND

Pit vipers, also known as crotalids, are a group of snakes including rattlesnakes, copperheads, and cottonmouths (water moccasins). Crotalids have a broad geographic distribution across the United States, and bites from these snakes can carry significant morbidity. Their envenomations are characterized by local tissue effects, hematologic effects, and systemic effects. Envenomations are generally treated with 1 of 2 antivenoms available in the United States.

OBJECTIVE

We developed a series of clinical questions to assist and guide the emergency physician in the acute management of a patient envenomated by a crotalid.

METHODS

We conducted a PubMed literature review from January 1970 to May 2020 in English for articles with the keywords "bite" and "crotalidae."

RESULTS

Our literature search resulted in 177 articles. A total of 33 articles met criteria for rigorous review and citation in the development of these consensus guidelines.

CONCLUSIONS

Patients should be initially evaluated, stabilized, and assessed for local effects, hematologic effects, and systemic toxicity suggestive of envenomation. Antivenom should be given if toxic effects are present. Surgical intervention including debridement and fasciotomy should be avoided. Prophylactic antibiotics are not necessary.

"Botched": A Case Report of Silicone Embolism Syndrome After Penile and Scrotal Injection

INTRODUCTION

Silicone has been commonly used for both major and minor plastic and reconstructive surgery for decades. Due to the high costs associated with minor cosmetic procedures and plastic surgery, the unauthorized use of silicone injections by laypersons has become increasingly common. Improper or illegal subcutaneous injectable silicone has caused significant pulmonary complications and neurological complications, which can range from mild chest pain, hypoxia, and respiratory failure to coma and altered mental status.

CASE REPORT

We present a patient who had a rare complication of respiratory failure secondary to silicone embolism syndrome (SES). SES is a rare, potentially deadly complication and has been associated with subcutaneous silicone injections. The diagnosis of SES can be challenging and requires a thorough patient history indicating recent cosmetic procedures.

CONCLUSION

This case describes the first case of SES of a male patient who presented to a community emergency department complaining of dyspnea after an episode of self-administered injectable silicone into his penis and scrotum and who developed SES-induced respiratory failure.

Restraint physiology: A review of the literature

Law-enforcement often uses forensic restraints to control individuals and often these individuals are placed in positions and with various amounts of weight used to hold them in place. There has been a moderate amount of research performed on humans in this field of study to assess the physiologic impact of the positions and weight on ventilatory and cardiovascular parameters. This review discusses the scientific medical literature on the use of restraints and restraint position including the use of weight force and aggregates the findings in specific physiologic areas, such as impact on blood pressure, heart rate, and ventilatory parameters.

Clinical Features of Patients with COVID-19: is Temperature Screening Useful?

Background

As many businesses reopen after government-induced restrictions, many public agencies and private companies, such as banks, golf courses, and stores, are using temperature screening to assess for possible coronavirus disease 2019 (COVID-19) infection both for patrons and for employees.

Objective

We assessed the frequency of a fever ≥100.4°F and other symptoms associated with COVID-19 among patients in the emergency department (ED) who were tested in the ED for the illness.

Methods

This is a retrospective review of data from patients who were tested for acute COVID-19 infection from March 10, 2020 through June 30, 2020 at two EDs within the same health care system. Data collected included temperature, the presence or recent history of COVID-19–related symptoms, and COVID-19 test results. Descriptive statistics are reported for presenting fever and other COVID-19–related symptoms alone and in combination with presenting fever.

Results

A total of 6894 patients were tested for COVID-19. Among these, 330 (4.8%) tested positive for active infection. Of these patients, 64 (19.4%) presented with a fever ≥100.4°F (≥38.0°C). Increasing the number of COVID-19–related symptoms in combination with a presenting fever ≥100.4°F increased the number of people who could be identified as having a COVID-19 infection.

Conclusions

About a quarter of patients who were tested positive for COVID-19 in our ED did not have a fever at presentation ≥100.4°F. Using only temperature to screen for COVID-19 in the community setting will likely miss the majority of patients with active disease.

Assessment of stress markers in restrained individuals following physical stress with and without sham CED activation

INTRODUCTION

Law enforcement and pre-hospital care personnel often confront individuals who must be physically restrained. Many are under the influence of illicit substances, and law enforcement officers may need to use a controlled electrical device (CED) to gain control of the individual and they are often placed into the prone maximum restraint (PMR) position. These techniques have previously been evaluated for their physiologic effects. The purpose of this study was to investigate the psychological effects of anticipating and experiencing a sham CED activation in healthy human subjects who were exercised and restrained compared with no sham activation by assessing the differences in a panel of several known biomarkers of stress.

METHODS

We performed a randomized, crossover controlled human subject trial to study the stress associated with exercise, physical exhaustion, and restraint with and without an added psychological stress simulating the field use of a CED. Twenty five total subjects; each subject performed two different trials each consisting of a brief period of intense exercise on a treadmill to exhaustion followed by placement in the PMR with and without induced psychological stress. Blood samples were collected for analysis pre and post exercise, as well as 10 min after completion of the exercise. A panel of hormones and stress markers were measured.

RESULTS

We found no significant differences in any of the stress biomarkers measured between the two study groups. A trend towards higher levels of copeptin was measured in the sham CED activation arm.

CONCLUSION

During a brief period of intense exercise followed by the psychological stress of anticipated CED application, there did not appear to be statistically significant changes in the stress panel of biomarkers measured, only a trend towards significance for higher copeptin levels in the patients exposed to the psychological stress.

Management of Chimeric Antigen Receptor (CAR) T-Cell Toxicities: A Review and Guideline for Emergency Providers

BACKGROUND

Chimeric antigen receptor (CAR) T-cell therapy is an adoptive cellular immunotherapy that is being utilized more frequently due to its initial success in advanced-stage cancers. Unfortunately, CAR T-cell therapy is often associated with acute systemic toxicities, including cytokine release syndrome (CRS) and CAR T-cell-associated neurotoxicity (neurotoxicity).

OBJECTIVE

We created a review that addresses the potential common emergency department (ED) presentations associated with CAR T-cell therapy. We reviewed the relevant research and clinical guidelines to develop a guide tailored toward addressing the needs of the emergency medicine community to manage these complications. In addition, a case is presented and the evaluation and management of CRS and neurotoxicity are reviewed in detail.

DISCUSSION

Despite CAR T-cell designs showing promising results, the risk of acquiring an acute toxicity is high, with CRS and neurotoxicity reported most often. The systemic toxicities associated with these adverse events can lead to end-organ damage and compromise the patient acutely or jeopardize the continuation in treatment of their underlying malignancy. Depending on the severity of the toxicity, treatment typically starts with vigilant supportive care, but may include administration of tocilizumab and possibly high-dose corticosteroids if the toxicity is deemed of high severity.

CONCLUSIONS

With the increasing administration of CAR T-cell therapy, emergency physicians will likely encounter more patients with associated adverse events, including CRS and neurotoxicity. It is increasingly important that emergency physicians are aware of these potential toxicities in order to rapidly diagnose and treat patients undergoing CAR T-cell therapy.

Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest

BACKGROUND

Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known.

METHODS

In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration.

RESULTS

Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06-1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5-9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02-1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7-8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66-1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74-1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant.

CONCLUSIONS

We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

Systematic Review: The Role of Intravenous and Oral Contrast in the Computed Tomography Evaluation of Acute Appendicitis

BACKGROUND

This systematic review provides practicing emergency physicians updated information regarding the role of oral and intravenous contrast in the computed tomography (CT) evaluation of acute appendicitis.

METHODS

A PubMed literature search was conducted from January 1, 1996 to December 31, 2018 and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review.

RESULTS

Fifty-seven articles met criteria for rigorous review, of which 14 were appropriate for citation in this review. Excellent evidence shows that oral contrast does not improve the test characteristics of CT with intravenous contrast (IVCT) in the evaluation of adults suspected of having acute appendicitis. Good evidence shows that noncontrast abdominal CTs have excellent test characteristics for this same group of patients.

CONCLUSIONS

Considering its downsides and lack of utility, the medical literature does not support using oral contrast in the evaluation of acute appendicitis. There is no direct evidence showing that IVCT is better than a noncontrast CT in the evaluation of acute appendicitis; however, the available literature is consistent with slightly better test characteristics for IVCTs. Still, if IVCT cannot be obtained in a timely manner, noncontrast CTs are extremely accurate in detecting this disease.

Variation in Bystander Cardiopulmonary Resuscitation Delivery and Subsequent Survival From Out-of-Hospital Cardiac Arrest Based on Neighborhood-Level Ethnic Characteristics

BACKGROUND

Bystander cardiopulmonary resuscitation (B-CPR) delivery and survival after out-of-hospital cardiac arrest vary at the neighborhood level, with lower survival seen in predominantly black neighborhoods. Although the Hispanic population is the fastest-growing minority population in the United States, few studies have assessed whether the proportion of Hispanic residents in a neighborhood is associated with B-CPR delivery and survival from out-of-hospital cardiac arrest. We assessed whether B-CPR rates and survival vary by neighborhood-level ethnicity. We hypothesized that neighborhoods with a higher proportion of Hispanic residents have lower B-CPR rates and lower survival.

METHODS

We conducted a retrospective cohort study using data from the Resuscitation Outcomes Consortium Epistry at US sites. Neighborhoods were classified by census tract based on percentage of Hispanic residents: <25%, 25% to 50%, 51% to 75%, or >75%. We independently modeled the likelihood of receipt of B-CPR and survival by neighborhood-level ethnicity controlling for site and patient-level confounding characteristics.

RESULTS

From 2011 to 2015, the Resuscitation Outcomes Consortium collected 27 481 US arrest events; after excluding pediatric arrests, emergency medical services-witnessed arrests, or arrests occurring in a healthcare or institutional facility, 18 927 were included. B-CPR was administered in 37% of events. In neighborhoods with <25% Hispanic residents, B-CPR was administered in 39% of events, whereas it was administered in 27% of events in neighborhoods with >75% Hispanic residents. Compared with <25% Hispanic neighborhoods in a multivariable analysis, out-of-hospital cardiac arrest in predominantly Hispanic neighborhoods had lower B-CPR rates (51% to 75% Hispanic: odds ratio, 0.79 [CI, 0.65-0.95], P=0.014; >75% Hispanic: odds ratio, 0.72 [CI, 0.55-0.96], P=0.025) and lower survival rates (global P value 0.029; >75% Hispanic: odds ratio, 0.56 [CI, 0.34-0.93], P=0.023).

CONCLUSIONS

Individuals with out-of-hospital cardiac arrest in predominantly Hispanic neighborhoods were less likely to receive B-CPR and had lower likelihood of survival. These findings suggest a need to understand the underlying disparities in cardiopulmonary resuscitationdelivery and an unmet cardiopulmonary resuscitationtraining need in Hispanic communities.

Short-term prognostic implications of serum and urine neutrophil gelatinase-associated lipocalin in acute heart failure: findings from the AKINESIS study

AIMS

Kidney impairment has been associated with worse outcomes in acute heart failure (AHF), although recent studies challenge this association. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel biomarker of kidney tubular injury. Its prognostic role in AHF has not been evaluated in large cohorts. The present study aimed to determine if serum NGAL (sNGAL) or urine NGAL (uNGAL) is superior to creatinine for predicting short-term outcomes in AHF.

METHODS AND RESULTS

The study was conducted in an international, multicentre, prospective cohort consisting of 927 patients with AHF. Admission and peak values of sNGAL, uNGAL and uNGAL/urine creatinine (uCr) ratio were compared to admission and peak serum creatinine (sCr). The composite endpoints were death, initiation of renal replacement therapy, heart failure (HF) readmission and any emergent HF-related outpatient visit within 30 and 60 days, respectively. The mean age of the cohort was 69 years and 62% were male. The median length of stay was 6 days. The composite endpoint occurred in 106 patients and 154 patients within 30 and 60 days, respectively. Serum NGAL was more predictive than uNGAL and the uNGAL/uCr ratio but was not superior to sCr [area under the curve: admission sNGAL 0.61, 95% confidence interval (CI) 0.55-0.67, and 0.59, 95% CI 0.54-0.65; peak sNGAL: 0.60, 95% CI 0.54-0.66, and 0.57, 95% CI 0.52-0.63; admission sCr: 0.60, 95% CI 0.54-0.64, and 0.59, 95% CI 0.53-0.64; peak sCr: 0.61, 95% CI 0.55-0.67, and 0.59, 95% CI 0.54-0.64, at 30 and 60 days, respectively]. NGAL was not predictive of the composite endpoint in multivariate analysis.

CONCLUSIONS

Serum NGAL outperformed uNGAL but neither was superior to admission or peak sCr for predicting adverse events.

Utility of Shunt Series in the Evaluation of Ventriculoperitoneal Shunt Dysfunction in Adults

BACKGROUND

When patients present to emergency departments (EDs) with symptoms suspicious for ventriculoperitoneal shunt malfunction, evaluation often includes imaging of the shunt with both computed tomography (CT) of the head without contrast and a plain radiograph "shunt series" (SS). Recent literature has called into question the diagnostic value of the SS for the detection of ventriculoperitoneal shunt complications, suggesting that the plain radiographs provide redundant information and unnecessary exposure to radiation.

OBJECTIVE

The aim of our study was to assess the frequency of abnormal SS plain radiography and head CT in the evaluation of shunt malfunction in all adult ED patients and to measure the association of abnormalities on CT and SS with surgical intervention.

METHODS

We performed a retrospective chart review of all emergency department encounters at an urban level I trauma center between August 1, 2013 and October 3, 2018 in which an SS and head CT examination were performed within 24 h of each other. We described the results of imaging studies qualitatively and descriptive statistics were performed.

RESULTS

Positive findings on CT were significantly associated with the decision to proceed to surgery. Positive findings on SS, however, were not significantly associated with the decision to proceed to surgery.

CONCLUSIONS

The potential information gained from SS and convenience of ordering simultaneously with head CT does not appear to outweigh the risk of increased radiation exposure to the patient, the additional costs of the study, and the potential delay in time to head CT. These findings support the initial use of head CT in evaluation of shunt malfunction.

B-type natriuretic peptide trend predicts clinical significance of worsening renal function in acute heart failure

AIMS

In acute heart failure (AHF), relationships between changes in B-type natriuretic peptide (BNP) and worsening renal function (WRF) and its prognostic implications have not been fully determined. We investigated the relationship between WRF and a decrease in BNP with in-hospital and 1-year mortality in AHF.

METHODS AND RESULTS

The Acute Kidney Injury NGAL Evaluation of Symptomatic heart faIlure Study (AKINESIS) was a prospective, international, multicentre study of AHF patients. Severe WRF (sWRF) was a sustained increase of ≥44.2 μmol/L (0.5 mg/dL) or ≥50% in creatinine, non-severe WRF (nsWRF) was a non-sustained increase of ≥26.5 μmol/L (0.3 mg/dL) or ≥50% in creatinine, and WRF with clinical deterioration was nsWRF with renal replacement therapy, inotrope use, or mechanical ventilation. Decreased BNP was defined as a ≥30% reduction in the last measured BNP compared to admission BNP. Among 814 patients, the incidence of WRF was not different between patients with or without decreased BNP (nsWRF: 33% vs. 31%, P = 0.549; sWRF: 11% vs. 9%, P = 0.551; WRF with clinical deterioration: 8% vs. 10%, P = 0.425). Decreased BNP was associated with better in-hospital and 1-year mortality regardless of WRF, while WRF was associated with worse outcomes only in patients without decreased BNP. In multivariate Cox regression analysis, decreased BNP, sWRF, and WRF with clinical deterioration were significantly associated with 1-year mortality.

CONCLUSIONS

Decreased BNP was associated with better in-hospital and long-term outcomes. WRF was only associated with adverse outcomes in patients without decreased BNP.

Variation in Survival After Out-of-Hospital Cardiac Arrest Between Emergency Medical Services Agencies

Importance

Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood.

Objective

To quantify variation in patient outcomes after OHCA across EMS agencies.

Design, Setting, and Participants

This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018.

Exposure

Treating EMS agency.

Main Outcomes and Measures

The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies.

Results

We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]).

Conclusions and Relevance

We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables.

Universal HIV and Birth Cohort HCV Screening in San Diego Emergency Departments

Universal HIV and HCV screening in emergency departments (ED) can reach populations who are less likely to get tested otherwise. The objective of this analysis was to evaluate universal opt-out HIV and HCV screening in two EDs in San Diego. HIV screening for persons aged 13-64 years (excluding persons known to be HIV+ or reporting HIV testing within last 12 months) was implemented using a 4th generation HIV antigen/antibody assay; HCV screening was offered to persons born between 1945 and 1965. Over a period of 16 months, 12,575 individuals were tested for HIV, resulting in 33 (0.26%) new HIV diagnoses, of whom 30 (90%) were successfully linked to care. Universal screening also identified 74 out-of-care for >12-months HIV+ individuals of whom 50 (68%) were successfully relinked to care. Over a one-month period, HCV antibody tests were conducted in 905 individuals with a seropositivity rate of 9.9% (90/905); 61 seropositives who were newly identified or never treated for HCV had HCV RNA testing, of which 31 (51%) resulted positive (3.4% of all participants, including 18 newly identified RNA positives representing 2% of all participants), and 13/31 individuals (42%) were linked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >7-fold, underlining the importance of HCV screening in EDs.

Systematic Review: The Role of Thrombolysis in Intermediate-Risk Pulmonary Embolism

BACKGROUND

This systemic review provides practicing emergency physicians updated information about the role of thrombolysis in the treatment of intermediate-risk pulmonary embolism.

METHODS

A PubMed literature search from January 1, 2005 to December 31, 2018 was conducted and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review.

RESULTS

Sixty-three articles met criteria for rigorous review, of which 13 were appropriate for citation in this review. Of these 13, there were 6 prospective studies and 7 retrospective studies.

CONCLUSIONS

Thrombolysis, either catheter-directed or systemic, is a treatment option in the management of patients with intermediate-risk pulmonary embolism and a high likelihood of clinical deterioration. Each method of thrombolysis carries risks and benefits. Based on the available evidence, transfer to a facility for the purpose of catheter-directed thrombolysis is not recommended.

Systematic Review: The Role of Thrombolysis in Intermediate-Risk Pulmonary Embolism

BACKGROUND

This systemic review provides practicing emergency physicians updated information about the role of thrombolysis in the treatment of intermediate-risk pulmonary embolism.

METHODS

A PubMed literature search from January 1, 2005 to December 31, 2018 was conducted and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review.

RESULTS

Sixty-three articles met criteria for rigorous review, of which 13 were appropriate for citation in this review. Of these 13, there were 6 prospective studies and 7 retrospective studies.

CONCLUSIONS

Thrombolysis, either catheter-directed or systemic, is a treatment option in the management of patients with intermediate-risk pulmonary embolism and a high likelihood of clinical deterioration. Each method of thrombolysis carries risks and benefits. Based on the available evidence, transfer to a facility for the purpose of catheter-directed thrombolysis is not recommended.

Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public

BACKGROUND

Bystander cardiopulmonary resuscitation (BCPR) improves survival from out-of-hospital cardiac arrest (OHCA), yet BCPR rates remain low. It is unknown whether BCPR delivery disparities exist based on victim gender. We measured BCPR rates by gender in private and public environments, hypothesizing that females would be less likely than males to receive BCPR in public settings, with an associated difference in survival to hospital discharge.

METHODS AND RESULTS

We analyzed data from adult, nontraumatic OHCA events within the Resuscitation Outcomes Consortium registry (2011-2015). Using logistic regression, we modeled the likelihood of receiving BCPR by gender, including patient-level variables, stratified by location. A cohort of 19 331 OHCAs was assessed. Mean age was 64±17 years, and 63% (12 225/19 331) were male. Overall, 37% of OHCA victims received bystander CPR. In public locations, 39% (272/694) of females and 45% (1170/2600) of males received BCPR ( P<0.01), whereas in private settings, 35% (2198/6328) of females and 36% (3364/9449) of males received BCPR ( P=NS). Among public OHCAs, males had significantly increased odds of receiving BCPR compared with females (odds ratio, 1.27; 95% CI, 1.05-1.53; P=0.01); this was not the case in the private setting (odds ratio, 0.93; 95% CI, 0.87-1.01; P=NS). Controlling for site, age, and race, BCPR was significantly associated with survival to hospital discharge (odds ratio, 1.69; 95% CI, 1.54-1.85; P<0.01); in this model, males had 29% increased odds of survival compared with females (odds ratio, 1.29; 95% CI, 1.17-1.42; P<0.01).

CONCLUSIONS

Males had an increased likelihood of receiving BCPR compared with females in public. BCPR improved survival to discharge, with greater survival among males compared with females.

EXCITATION study: Unexplained in-custody deaths: Evaluating biomarkers of stress and agitation

BACKGROUND

Law enforcement personnel often confront violent and dangerous individuals suffering from Excited Delirium Syndrome (ExDS) who need emergent medical evaluation and treatment to optimize the best outcomes for this potentially lethal medical emergency. These subjects typically require physical restraint and use of force measures to control them. We sought to determine if stress-related biomarkers can differentiate ExDS subjects when compared with agitation and stress under other circumstances, including agitation and extreme physical exhaustion and restraint coupled with emotional stressors.

METHODS

This was a prospective multi-center study enrolling a convenience sample of patients who presented with agitation or ExDS. Patients were enrolled from three academic emergency departments (ED), two in the United States and one in Canada. Three study groups (SG) included: SG1) patients brought to the ED with ExDS based on the use of standardized clinical criteria; SG2) ED patients with acute agitation who were not in a clinical state of ExDS but required sedation; SG3) a laboratory control group of subjects exercised to physical exhaustion, restrained, and psychologically stressed with threat of Conducted Energy Device (CED) activation. We examined a panel of stress-related biomarkers, including norepinephrine (NE), cortisol, copeptin, orexin A, and dynorphin (Dyn) from the blood of enrolled subjects.

RESULTS

A total of 82 subjects were enrolled: 31 in the agitation group, 21 in the ExDS group, and 30 in the laboratory control group. Data were analyzed, comparing the findings between ExDS and the two other groups to determine if specific stress-related biomarkers are associated with ExDS. Biomarker comparisons between subjects identified with ExDS, agitation, and control groups demonstrated that cortisol levels were more elevated in the ExDS group compared with the other groups. Orexin was only significant in ExDs (with Agitated tendency but lot of variability in the group). NE and Dyn increased as response to stress in Agitated and ExDS.

CONCLUSIONS

Cortisol levels were more elevated in subjects in the ExDS group compared with the other comparison groups and orexin was elevated in ExDS compared to controls, a trend that did not reach statistical significance in the agitated group. The clinical or diagnostic significance of these difference have yet to be defined and warrants further study.

Association of Neighborhood Demographics With Out-of-Hospital Cardiac Arrest Treatment and Outcomes: Where You Live May Matter

Importance

We examined whether resuscitation care and outcomes vary by the racial composition of the neighborhood where out-of-hospital cardiac arrests (OHCAs) occur.

Objective

To evaluate the association between bystander treatments (cardiopulmonary resuscitation and automatic external defibrillation) and timing of emergency medical services personnel on OHCA outcomes according to the racial composition of the neighborhood where the OHCA event occurred.

Design, Setting, and Participants

This retrospective observational cohort study examined patients with OHCA from January 1, 2008, to December 31, 2011, using data from the Resuscitation Outcomes Consortium. Neighborhoods where OHCA occurred were classified by census tract, based on percentage of black residents: less than 25%, 25% to 50%, 51% to 75%, or more than 75%. Multilevel mixed-effects logistic regression modeling examined the association between racial composition of neighborhoods and OHCA survival, adjusting for patient, neighborhood, and treatment characteristics.

Main Outcomes and Measures

Survival to discharge, return of spontaneous circulation on emergency department arrival, and favorable neurologic status at discharge.

Results

We examined 22 816 adult patients with nontraumatic OHCA at Resuscitation Outcomes Consortium sites in the United States. The median age of patients with OHCA was 64 years (interquartile range [IQR], 51-78). Compared with patients who experienced OHCA in neighborhoods with a lower proportion of black residents, those in neighborhoods with more than 75% black residents were slightly younger, were more frequently women, had lower rates of initial shockable rhythm, and less frequently experienced OHCA in a public location. The percentage of patients with OHCA receiving bystander cardiopulmonary resuscitation or a lay automatic external defibrillation was inversely associated with the percentage of black residents in neighborhoods. Compared with OHCA in predominantly white neighborhoods (<25% black), those with OHCA in mixed to majority black neighborhoods had lower adjusted survival rates to hospital discharge (25%-50% black: odds ratio, 0.76; 95% CI, 0.61-0.93; 51%-75% black: odds ratio, 0.67; 95% CI, 0.49-0.90; >75% black: odds ratio, 0.63; 95% CI, 0.50-0.79; P < .001). There was similar mortality risk for black and white patients with OHCA in each neighborhood racial quantile. When the primary model included geographic site, there was an attenuated nonsignificant association between racial composition in a neighborhood and survival.

Conclusions and Relevance

Those with OHCA in predominantly black neighborhoods had the lowest rates of bystander cardiopulmonary resuscitation and automatic external defibrillation use and significantly lower likelihood for survival compared with predominantly white neighborhoods. Improving bystander treatments in these neighborhoods may improve cardiac arrest survival.

Screening Tools Validated in the Outpatient Pain Management Setting Poorly Predict Opioid Misuse in the Emergency Department: A Pilot Study

BACKGROUND

Currently, no universally accepted methods exist to assess drug-related aberrant behaviors in emergency department (ED) patients. There are several screening tools to identify opioid misuse in patients with chronic pain, however, the validity of these screening tools to assess for misuse within the ED remains unclear.

OBJECTIVES

This study investigated the effectiveness of three commonly used screening tools, previously validated in outpatient pain management settings, to assess risk of opioid misuse in ED patients.

METHODS

This was a prospective observational study of 154 participants (median age 50 years; 49.6% female) presenting to an academic ED for a chief complaint of pain ≥ 6 months or an opioid refill request. Participants completed the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain-Revised, and the Current Opioid Misuse Measure. Scores for each were compared with electronic medical record (EMR) data alone or a reference standard comprising EMR + statewide prescription drug monitoring program (PDMP) + medical examiner database.

RESULTS

Using the combined reference standard, 55.8% of participants displayed at least one aberrant behavior. Regardless of the reference standard, the test characteristics of these screening tools were modest at best, with likelihood ratios close to 1.

CONCLUSION

Three screening tools previously validated in outpatient pain management settings poorly categorized risk among ED patients with chronic noncancer pain or requests for opioid refills, and should not be used to assess drug-aberrant behaviors in the ED. Review of the EMR alone or together with the PDMP may be more useful methods to assess drug-aberrant behaviors in the ED setting.

Timing of fatal BASE jumping incidents: 1981-2018

BASE jumping, or fixed object parachuting, is a high-risk sport that has evolved significantly since its inception in the 1960s. Differences in parachute technology, teaching methods, jumping locations, practices, and popularity, among other factors, have qualitatively transformed the sport, particularly since 2000. The current study seeks to better understand how the rate of BASE jumping fatalities have changed as BASE jumping has grown. Using data from the BASE Fatality List, a resource continuously compiled by the BASE community with information on all known BASE fatalities, temporal trends in BASE fatalities that accompanied these changes over time are explored. The number of annual fatalities stayed between 0 and 5 from 1981 to 1999, but around the year 2000 began an upward trend that has continued through 2018. There appears to be large seasonal variation in monthly fatality rate, with the most deaths occurring in the northern hemisphere's summer months, the peak being in August, and the fewest deaths occurring in the northern hemisphere's winter months. The years 2013-2018 have continued the increasing fatality trend, but have otherwise deviated through increased variability in short-term and seasonal trends. Potential causes of these short-term trends, changing trends in the causes of fatal accidents, factors potentially unique to anomalous events, and directions for future research are also discussed.

Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis

BACKGROUND

Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital's emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States.

OBJECTIVE

This study describes the LWBS population at a multi-hospital academic health system.

METHODS

This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed.

RESULTS

During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7 days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period.

CONCLUSIONS

LWBS patients are high ED utilizers who may be effectively targeted by "hotspotting." Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.