Notes

Standing at the edge regarding mortality; Five-year audit of your urgent situation division of a tertiary care clinic inside a reduced resource setup.
Presence of ethanol (EtOH) may alter the relationship between blood lactate concentrations and mortality. This study compares lactate-associated mortality risk in the presence and absence of EtOH.

We performed a retrospective cohort study including all patients, age>17 years, presenting from January 2012-December 2018, to an urban, academic emergency department, with a clinically measured lactate. Data were electronically abstracted from the medical record. The primary outcome was 28-day in-hospital mortality. Patients were grouped by EtOH test results as follows 1) present (any EtOH detected), 2) absent (EtOH concentration measured and not detected), or 3) not ordered. Marginal analysis was used to calculated probability of mortality for fixed values of lactate and model covariates.

Of 40,956 adult emergency department patients with measured lactate, we excluded 768 (1.89%) for lactate>10.0mmol/L, leaving 40,240 for analysis 4,066 (10.1%) EtOH present, 10,819 (26.9%) EtOH absent, 25,355 (63%) EtOH not ordered. Of these, 1790 (4.4%) had 28-day in-hospital mortality. Marginal probability of mortality calculated for specific lactate values found less risk for EtOH Present patients versus EtOH absent patients at lactate 0.0mmol/L (0.8% [95%CI 0.5-1.2%] vs 3.2% [2.8-3.6%]), 2.0mmol/L (1.5% [1.1-1.9%] vs 4.0% [3.7-4.3%]), 4.0mmol/L (2.6% [2.2-3.1%] vs 5.0% [4.6-5.4%]), until 6.0mmol/L (4.5% [3.7-5.4%] vs 6.2% [5.4-7.0%]).

EtOH presence significantly alters lactate-associated mortality risk when lactate<6.0mmol/L. Emergency department clinicians should interpret these lactate values with caution and consider other data for risk stratification when EtOH is present.
EtOH presence significantly alters lactate-associated mortality risk when lactate less then 6.0 mmol/L. Emergency department clinicians should interpret these lactate values with caution and consider other data for risk stratification when EtOH is present.
In prehospital and emergency settings, vasoactive medications may need to be started through a peripheral intravenous catheter. Fear of extravasation and skin injury, with norepinephrine specifically, may prevent or delay peripheral vasopressor initiation, though studies from adults suggest the actual risk is low. We sought to study the risk of extravasation and skin injury with peripheral administration of norepinephrine in children in the prehospital setting.

We performed a retrospective study of pediatric patients(≤18 years) who received a vasopressor during prehospital transport. We collected data from retrieval and hospital records from 2 pediatric medical retrieval teams in the Paris/Ile-de-France region. Patients were eligible if they had documentation of distributive or obstructive shock and administration of norepinephrine through a peripheral catheter (intravenous or intraosseous) during retrieval. The primary outcomes were the occurrence of extravasation and evidence of skin injury. We also exandation for this practice can be made.
In a 3-year sample of pediatric patients from a large metropolitan area, we found only 1 patient with evidence of any harm with peripheral administration of norepinephrine. This finding is consistent with the adult literature but requires multicenter and multiyear investigation before a firm recommendation for this practice can be made.
Currently, there are no guidelines to help triage nurses identify high-risk emergency department chest pain patients. Patient self-reporting of Emergency Department Assessment of Chest Pain Score (EDACS) could facilitate more reliable triage compared to nursing gestalt, but this novel concept is untested. This study hypothesizes that because EDACS requires minimal clinical gestalt to derive, self-reported EDACS (S-EDACS) at triage is likely to correlate well with traditional physician-reported EDACS (P-EDACS) and have potential application as a triage tool.

This single-center pilot prospective cohort study analyzed 60 patients who completed a self-reported questionnaire upon triage to determine their S-EDACS. This was matched against P-EDACS, derived from an identical questionnaire completed by the blinded treating physician. Secondary endpoint of major adverse cardiovascular events (MACE) within 30 days (all-cause mortality, myocardial infarction, coronary revascularization) was assessed by 2 blinded emergency physicians who independently reviewed the electronic medical records. S/P-EDACS also were benchmarked against nursing gestalt (based on triage to low/high-acuity areas) and emergency physician gestalt (disposition and admitting/discharge diagnoses).

There was perfect agreement between S/P-EDACS in this study (
=1.00). Fifteen patients (25.0%) had minor discordances in their absolute S/P-EDACS that did not affect risk stratification. Of these, 11/15 (73.3%) had higher S-EDACS, suggesting S-EDACS is more likely to safely overcall MACE risk. S-EDACS outperformed nursing gestalt, triaging a greater proportion of patients (71.7%vs 35.0%) as low risk without compromising patient safety, and demonstrated similar accuracy as emergency physician gestalt.

S-EDACS strongly correlates with P-EDACS with perfect agreement and has potential to be used as a triage tool.
S-EDACS strongly correlates with P-EDACS with perfect agreement and has potential to be used as a triage tool.
Paramedic students in the US are required to complete clinical placements to gain supervised experience with real patient encounters. Given wide variation in clinical placement practices, an evidence-based approach is needed to guide programs in setting realistic and attainable goals for students. This study's goal was to describe patient encounters and hours logged by paramedic students during clinical placements.

A retrospective review of prospectively collected quality assurance data entered by US paramedic students between 2010 and 2014 was conducted. De-identified electronic records entered in the Field Internship Student Data Acquisition Project (FISDAP) Skill Tracker database were included from consenting paramedic students whose records were audited and approved by instructors. Descriptive statistics were calculated.

A total of 10,645 students encountered 2,239,027 patients; most encounters occurred in hospital settings (n = 1,311,967, 59%). The median total number of patient encounters per para
Health care workers experience an uncertain risk of aerosol exposure during patient oxygenation. To improve our understanding of these risks, we sought to measure aerosol production during various approaches to oxygenation in healthy volunteers in an emergency department.

This was a prospective study conducted in an empty patient room in an academic ED. The room was 10 ft. long x 10 ft. wide x 9 ft. tall (total volume 900 ft
) with positive pressure airflow (1 complete turnover of air every 10 minutes). Five oxygenation conditions were used humidified high-flow nasal cannula (HFNC) at 3 flow rates [15, 30, and 60 liters per minute (LPM)], non-rebreather mask (NRB) at 1 flow rate (15 LPM), and closed-circuit continuous positive airway pressure (CPAP) using the ED ventilator; in all cases a simple procedural mask was used. Zosuquidar The NRB and HFNC at 30 LPM maneuvers were also repeated without the procedural mask, and CPAP was applied both with and without a filter. Each subject then sequentially underwent 8 totalrker safety.
Emergency departments (ED) are frequently the entryway to the health system for older, more ill patients. Because decisions made in the ED often influence escalation of care both in the ED and after admission, it is important for emergency physicians to understand their patients' goals of care.

To determine how well emergency physicians understand their patients' goals of care.

This was a prospective survey study of a convenience sample of ED patients 65 years and older presenting between February 18 and March 1, 2019 to an academic center with 77,000 annual visits. If a patient did not have decision-making capacity, a surrogate decision-maker was interviewed when possible. Two sets of surveys were designed, one for patients and one for physicians. The patient survey included questions regarding their goals of care and end-of-life care preferences. The physician survey asked physicians to select which goals of care were important to their patients and to identify which was the most important. Patient-phhe ED regarding patients' most important goal of care. Additionally, we found that most patients visiting the ED believe it is important to discuss goals of care with their physicians. Future work may focus on interventions to facilitate goals of care discussions in the ED.
We found poor agreement between patients and physicians in the ED regarding patients' most important goal of care. Additionally, we found that most patients visiting the ED believe it is important to discuss goals of care with their physicians. Future work may focus on interventions to facilitate goals of care discussions in the ED.Acute cardiogenic pulmonary edema is a highly unstable and potentially lethal condition that is most commonly associated with markedly elevated blood pressure (BP). Use of nitrates, diuretics, and non-invasive positive pressure ventilatory support are the mainstays of early intervention and stabilization. Use of high-dose bolus intravenous nitroglycerin, which causes both preload and afterload reduction, has shown significant promise in studies to date, reducing the need for endotracheal intubation (ETI) and intensive care unit admission. To date, the highest recorded total dose of nitroglycerin used during the initial stabilization of acute pulmonary edema has been 20 mg. Here, we describe a patient with end-stage renal disease who developed acute cardiogenic pulmonary edema and received a total of 59 mg nitroglycerin (56 mg push dose intravenous + 3 mg intravenous drip) over 41 minutes leading to successful stabilization and avoidance of ETI, facilitating rapid initiation of emergent hemodialysis.
To determine whether an emergency department (ED) education and empowerment intervention coupled with early risk assessment can help improve blood pressure (BP) in a high-risk population.

A hypertension emergency department intervention aimed at decreasing disparities (AHEAD2) is a 3-arm, single-site randomized pilot trial for feasibility in an urban academic ED. A total of 150 predominantly ethnic minorities with no primary care provider and severely elevated blood pressure (BP) (≥160/100 mm Hg) were enrolled over 10 months. Participants were randomized into 1 of 3 study arms (1) enhanced usual care (EUC), (2) ED-initiated screening, brief intervention, and referral for treatment (ED-SBIRT), or (3) ED- SBIRT plus a 48-72 hours post-acute care hypertension transition clinic (ED-SBIRT+PACHT-c). Primary outcomes were change in systolic and diastolic BP (SBP and DBP) from baseline to 9 months. Secondary outcomes were BP control (BP <140/90 mm Hg), changes in hypertension knowledge, medication adherence, auggest that a multicomponent intervention comprising of ED education and empowerment coupled with early risk assessment may help improve BP in a high-risk population.
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