Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi.

Objectives: Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms.

A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke.

Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT.

First-Time Seizure Patients have High Rate of Abnormalities on Emergency Department Performed Brain Computed Tomography: A Prospective Study.

Background: First-time seizures comprise 15% to 35% of all seizure-related complaints in the emergency department (ED). Emergent neuroimaging of first-time seizure patients is recommended by both the American Academy of Neurology and American College of Emergency Physicians. However, most of these studies are over 10 years old and included both adults and children.

Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy.

Introduction: In the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT.

Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction.

Background: There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described.

Objective: We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG.

Evolution of endovascular stroke centers and disparities in access to stroke care in four Northeastern states: 2015-2019.

Objectives: Disparities exist throughout our healthcare system, especially related to access to care. Advanced stroke care for strokes is only available at selected endovascular centers (ESCs) in the United States. Although the number of ESCs increase each year, this does not necessarily reflect increased access to care.

The LIMIT-NI clinical decision instrument reduces neuroimaging compared to unstructured clinician judgement in recurrent seizure patients.

Objective: The LIMIT clinical decision instrument (CDI) was published in 2021 to safely reduce neuroimaging in patients with recurrent seizures. The LIMIT CDI had a sensitivity of 90%, negative predictive value of >99.9%, and reduced neuroimaging by 13.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care.

Background: Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients.

Clinical factors associated with significant coronary lesions following out-of-hospital cardiac arrest.

Objectives: Out-of-hospital cardiac arrest (OHCA) afflicts >350,000 people annually in the United States. While postarrest coronary angiography (CAG) with percutaneous coronary intervention (PCI) has been associated with improved survival in observational cohorts, substantial uncertainty exists regarding patient selection for postarrest CAG. We tested the hypothesis that symptoms consistent with acute coronary syndrome (ACS), including chest discomfort, prior to OHCAs are associated with significant coronary lesions identified on postarrest CAG.

The LIMIT clinical decision instrument reduces neuroimaging compared to unstructured clinician judgement in recurrent seizures.

Introduction: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. Previously, we have validated the LIMIT (Let's Image Malignancy, Intracranial Hemorrhage, and Trauma) clinical decision instrument (CDI) study to determine which patients with recurrent seizures require emergent neuroimaging. The LIMIT CDI had a negative predictive value (NPV) of 99.

Rate of Decompensation of Normoxic Emergency Department Patients with SARS-CoV-2.

Introduction: As of October 30, 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over 44 million people worldwide and killed over 1.1 million people. In the emergency department (ED), patients who need supplemental oxygen or respiratory support are admitted to the hospital, but the course of normoxic patients with SARS-CoV-2 infection is unknown.

Upgrades to intensive care: The effects of COVID-19 on decision-making in the emergency department.

Introduction: The initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units.

Methods: The number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses.

Evaluating the utility of Rapid Response EEG in emergency care.

Background: Timely management of non-convulsive status epilepticus (NCSE) is critical to improving patient outcomes. However, NCSE can only be confirmed using electroencephalography (EEG), which is either significantly delayed or entirely unavailable in emergency departments (EDs). We piloted the use of a new bedside EEG device, Rapid Response EEG (Rapid-EEG, Ceribell), in the ED and evaluated its impact on seizure management when used by emergency physicians.

Validation of a clinical decision instrument for emergent neuroimaging after a seizure: Let's image malignancy, intracranial hemorrhage, and trauma (LIMIT).

Background: Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. However, a CT exposes patients to 100 times more radiation than a chest radiograph. Previously, we developed a four-item clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) do not require emergent neuroimaging.

Impact of a shelter-in-place order during the COVID-19 pandemic on the incidence of opioid overdoses.

Introduction: Since the beginning of the novel coronavirus (COVID-19) pandemic in the United States, there have been concerns about the potential impact of the pandemic on persons with opioid use disorder. Shelter-in-place (SIP) orders, which aimed to reduce the spread and scope of the virus, likely also impacted this patient population. This study aims to assess the role of the COVID-19 pandemic on the incidence of opioid overdose before and after a SIP order.

Males Receive Low-Tidal Volume Component of Lung Protective Ventilation More Frequently than Females in the Emergency Department.

Introduction: Mechanical ventilation is a commonly performed procedure in the emergency department (ED). Approximately 240,000 patients per year receive mechanical ventilation in the ED representing 0.23% of ED visits.

Derivation of a clinical decision instrument to identify patients with status epilepticus who require emergent brain CT.

Background: Studies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging.

Methods: This was a retrospective chart review of patients who presented to our emergency department with SE between 2010 and 2018.

A Case of Acute Traumatic Lumbar Paraspinal Compartment Syndrome.

Background: Compartment syndrome is a life-threatening complication of traumatic injury, most commonly, direct trauma. Back pain is a common cause of visits to the emergency department (ED) and often is treated without imaging or diagnostic testing. Lumbar paraspinal compartment syndrome is a rare cause of acute back pain.

Simple Changes to Emergency Department Workflow Improve Analgesia in Mechanically Ventilated Patients.

Introduction: In 2013 the Society for Critical Care Medicine (SCCM) published guidelines for the management of pain and agitation in the intensive care unit (ICU). These guidelines recommend using an analgesia-first strategy in mechanically ventilated patients as well as reducing the use of benzodiazepines. Benzodiazepines increase delirium in ICU patients thereby increasing ICU length of stay.

Characteristics of Trauma Patients With Potential Cervical Spine Injuries Underimmobilized by Prehospital Providers.

Study Design: This study was a retrospective chart review to determine characteristics of patients under-immobilized by prehospital providers.

Objective: Our goal was to examine the characteristics of patients who met the criteria for spinal immobilization but were inappropriately cleared.

Summary Of Background Data: Many emergency medical services (EMS) use selective spinal immobilization (SSI) based on the NEXUS criteria.

Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment.

Introduction: Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting. Hypothesis This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting.