Spontaneous coronary artery dissection and acute myocardial infarction in women.

Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of acute coronary syndrome, acute myocardial infarction, and sudden death in young patients, particularly women, presenting to the emergency department with chest pain. It is the most common cause of nonatherosclerotic coronary artery disease in women <50 years of age. Current guidelines for SCAD management come from case series that have demonstrated low success rates and high rates of complications with percutaneous coronary intervention.

Validation of a simplified comorbidity evaluation predicting clinical outcomes among patients with coronavirus disease 2019 - A multicenter retrospective observation study.

Objectives: We compared and validated the performance accuracy of simplified comorbidity evaluation compared to the Charlson Comorbidity Index (CCI) predicting COVID-19 severity. In addition, we also determined whether risk prediction of COVID-19 severity changed during different COVID-19 pandemic outbreaks.

Methods: We enrolled all patients whose SARS-CoV-2 PCR tests were performed at six different hospital Emergency Departments in 2020.

Anaphylaxis due to Hymenoptera sting progressing to thoracic aortic dissection.

Here we present an 83-year-old woman with truncal pain, hypoxemia, and nausea after a Hymenoptera sting. Due to progressive truncal pain, emergent computed tomography angiography was ordered and confirmed an acute Stanford type A aortic dissection extending from the aortic root and terminating in the left common iliac artery. She was emergently transferred to a quaternary care center and managed surgically.

Effectiveness of an algorithm-based care pathway for patients with non-valvular atrial fibrillation presenting to the emergency department.

Objective: Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures.

Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial.

Background: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial.

Methods: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible.

Timing of Oversedation Events Following Opiate Administration in Hospitalized Patients.

Background: Unintended overdoses of opiate medications are potentially lethal events. Monitoring patients for oversedation is fundamental to ensuring safe use of opiates, and the timing of this evaluation is guided by the onset of action, time to max effect and duration of action of the opiate. The study's aim was to describe the timing of oversedation in relation to the predicted duration of action of the administered opiate.

Impact of emergency department opioid use on future health resource utilization among patients with migraine.

Objective: The purpose of this study was to evaluate the subsequent health resource utilization (HRU) between patients with migraine who received opioid medications at their emergency department (ED) visits ("opioid recipients") versus patients with migraine who did not receive opioid medications at their ED visits ("non-recipients").

Background: Previous studies have found that opioid use is common among patients with migraine at emergency settings. Medication overuse, especially the use of opioids, is associated with migraine progression, which can ultimately lead to substantial health resource use and costs.

Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury.

Background: No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.

Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.

Over-Testing for Suspected Pulmonary Embolism in American Emergency Departments: The Continuing Epidemic.

Background: No recent data have investigated rates of diagnostic testing for pulmonary embolism (PE) in US emergency departments (EDs), and no data have examined computed tomographic pulmonary angiography (CTPA) rates in subgroups at high risk for adverse imaging outcomes, including young women and children. We hypothesized that over-testing for PE remains a problem.

Methods And Results: We used electronic health record and billing data for 16 EDs in Indiana and 11 hospitals in the Dallas-Fort Worth area from 2016 to 2019 to locate ED patients who had any of the following: D-dimer, CTPA, scintillation ventilation perfusion lung scanning or formal pulmonary angiography.

Computed Tomography Imaging in Aortic Dissection.

Emergency physicians often rely on a "triple-rule-out" computed tomography (CT) where image acquisition is timed to obtain image quality equivalent to dedicated coronary CT angiography, pulmonary CT angiography, and thoracic aorta CT angiography. This case highlights the importance of obtaining CT angiography dedicated to the aorta in the setting of high clinical suspicion for aortic disease if initial CT pulmonary angiogram is negative for aortic disease.

Critical Event Intervals in Determining Candidacy for Intravenous Thrombolysis in Acute Stroke.

Background: The aim of the study was to determine the optimal set point for the critical event benchmarks described in stroke guidelines and validate the ability of these goals to predict successful administration of intravenous thrombolysis within 60 min of hospital arrival.

Methods: This was a retrospective cohort analysis of patients with acute ischemic stroke who received intravenous thrombolysis following presentation to the emergency department. The national benchmarks for time intervals associated with the completion of critical events required to determine candidacy for thrombolysis were evaluated for the ability to predict successful administration of thrombolysis within 60 min of hospital arrival.

Comparison of outcomes in patients with intracranial hemorrhage on factor Xa inhibitors versus vitamin K antagonists treated with 4-factor prothrombin complex concentrate.

The relative clinical efficacy of 4-factor prothrombin complex concentrate (4F-PCC) in oral anticoagulant-associated intracranial hemorrhage is unknown, especially for factor Xa-inhibiting anticoagulants. We report short-term outcomes of patients with oral anticoagulant-associated intracranial hemorrhage on vitamin K antagonists and factor Xa inhibitors who were treated with 4F-PCC. This multicenter, observational study involved patients presenting to the emergency department in nine hospitals in an integrated health care delivery system in Texas between July 2013 and December 2015.

Overall survival and brain death frequency following out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality that is responsible for over 300,000 deaths in the United States each year. Underlying cardiac etiologies remain the most common culprit. Despite medical advances in the treatment of coronary artery disease, the mortality following OHCA remains dismal.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department.

Background: Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change.

Methods: We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015.

The effect of vertical split-flow patient management on emergency department throughput and efficiency.

Background: To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction.

Secondary traumatic stress in emergency medicine clinicians.

Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs).

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study.

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes.

Validation of clinical prediction scores in patients with primary intracerebral hemorrhage.

Background: Initial reports of the FUNC score suggest that it may accurately identify those patients suffering from intracerebral hemorrhage (ICH) with an ultra low chance of functional neurologic recovery. This study's aim is to validate the FUNC score and determine if it accurately identifies the cohort of patients with an ultra low chance of survival with good neurologic recovery.

Methods: Retrospective review of 501 consecutive primary ICH patients admitted from the Emergency Department to a large healthcare system.

Pilot study of a protocol to administer inhaled nitric oxide to treat severe acute submassive pulmonary embolism.

Objective: Inhaled nitric oxide has been reported to benefit patients with acute pulmonary embolism (PE). To date, all published literature has derived from case reports or case series conducted without a structured protocol. Here we report the results of a phase I trial with a predefined clinical protocol to treat patients with CT-demonstrated, submassive PE and moderate to severe dyspnoea.

The association between ambulance hospital turnaround times and patient acuity, destination hospital, and time of day.

Introduction: The availability of ambulances to respond to emergency calls is related to their ability to return to service from the hospital. Extended hospital turnaround times decrease the number of available unit hours ambulances are deployed, which in turn can increase coverage costs or sacrifice coverage.

Objective: To determine whether ambulance turnaround times were associated with patient acuity, destination hospital, and time of day.

Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest.

Background: Intraosseous (IO) needle insertion is often utilized in the adult population for critical resuscitation purposes. Standard insertion sites include the proximal humerus and proximal tibia, for which limited comparison data are available.

Objective: This study compared the frequencies of IO first-attempt success between humeral and tibial sites in out-of-hospital cardiac arrest.

The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrest.

Introduction: Therapeutic hypothermia has been shown to improve both mortality and neurologic outcomes following pulseless ventricular tachycardia and fibrillation. Animal data suggest intra-arrest induction of therapeutic hypothermia (IATH) improves frequency of return of spontaneous circulation (ROSC). Our objective was to evaluate the association between IATH and ROSC.

The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis.

Objective: Quantitative resuscitation consists of structured cardiovascular intervention targeting predefined hemodynamic end points. We sought to measure the treatment effect of quantitative resuscitation on mortality from sepsis.

Data Sources: We conducted a systematic review of the Cochrane Library, MEDLINE, EMBASE, CINAHL, conference proceedings, clinical practice guidelines, and other sources using a comprehensive strategy.