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Background: Identifying low-risk acute heart failure patients safe for discharge from the emergency department is a major unmet need., Methods and Results: A prospective, observational, multicenter pilot study targeting lower risk acute heart failure patients to determine whether hsTnT (high-sensitivity troponin T) identifies emergency department acute heart failure patients at low risk for rehospitalization and mortality. hsTnT was drawn at baseline and 3 hours. Phone follow-up occurred at 30 and 90 days. The primary end point composite of all-cause mortality, rehospitalization, and emergency department visits at 90 days (changed from 30 days because of lack of mortality events), analyzed using logistic regression. Secondary end points: 30- and 90-day all-cause mortality. hsTnT values less than the 99th percentile were defined as low hsTnT. Out of 527 enrolled patients, 499 comprised the initial analysis set. Of these, 332 had both 0- and 3-hour hsTnT drawn, of whom 319 completed 30 day follow-up. The average age was 62, 60% male, and 57% black. Median hsTnT was 26.4 ng/L (interquartile range, 15.1-44.3). There were 99 (21%) 30-day composite events, 13 (2.7%) deaths at 30 days, and 25 deaths (8.2%) at 90 days. Serial hsTnT values below the 99th percentile were not associated with a lower risk for the 90-day primary composite end point (odds ratio, 0.79; 95% CI, 0.42-1.50; P=0.4736). However, no deaths occurred in the low hsTnT group at 30 days with 1 death at 90 days., Conclusions: hsTnT did not identify patients at low risk for the primary outcome of rehospitalization, emergency department visits, and mortality at 90 days., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02592135.

Aims: Partial pressure of arterial carbon dioxide (PaCO 2 ) is a regulator of cerebral blood flow after brain injury. We sought to test the association between PaCO 2 after resuscitation from cardiac arrest and neurological outcome., Methods: A prospective protocol-directed cohort study across six hospitals., Inclusion Criteria: age ≥18, non-traumatic cardiac arrest, mechanically ventilated after return of spontaneous circulation (ROSC), and receipt of targeted temperature management. Per protocol, PaCO 2 was measured by arterial blood gas analyses at one and six hours after ROSC. We determined the mean PaCO 2 over this initial six hours after ROSC. The primary outcome was good neurological function at hospital discharge, defined a priori as a modified Rankin Scale ≤3. Multivariable Poisson regression analysis was used to test the association between PaCO 2 and neurological outcome., Results: Of the 280 patients included, the median (interquartile range) PaCO 2 was 44 (37-52) mmHg and 30% had good neurological function. We found mean PaCO 2 had a quadratic (inverted "U" shaped) association with good neurological outcome, with a mean PaCO 2 of 68 mmHg having the highest predictive probability of good neurological outcome, and worse neurological outcome at higher and lower PaCO 2 . Presence of metabolic acidosis attenuated the association between PaCO 2 and good neurological outcome, with a PaCO 2 of 51 mmHg having the highest predictive probability of good neurological outcome among patients with metabolic acidosis., Conclusion: PaCO 2 has a "U" shaped association with neurological outcome, with mild to moderate hypercapnia having the highest probability of good neurological outcome., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: Laboratory studies suggest elevated blood pressure after resuscitation from cardiac arrest may be protective; however, clinical data are limited. We sought to test the hypothesis that elevated postresuscitation mean arterial blood pressure is associated with neurologic outcome., Design: Preplanned analysis of a prospective cohort study., Setting: Six academic hospitals in the United States., Patients: Adult, nontraumatic cardiac arrest patients treated with targeted temperature management after return of spontaneous circulation., Interventions: Mean arterial blood pressure was measured noninvasively after return of spontaneous circulation and every hour during the initial 6 hours after return of spontaneous circulation., Measures and Main Results: We calculated the mean arterial blood pressure and a priori dichotomized subjects into two groups: mean arterial blood pressure 70-90 and greater than 90 mm Hg. The primary outcome was good neurologic function, defined as a modified Rankin Scale less than or equal to 3. The modified Rankin Scale was prospectively determined at hospital discharge. Of the 269 patients included, 159 (59%) had a mean arterial blood pressure greater than 90 mm Hg. Good neurologic function at hospital discharge occurred in 30% of patients in the entire cohort and was significantly higher in patients with a mean arterial blood pressure greater than 90 mm Hg (42%) as compared with mean arterial blood pressure 70-90 mm Hg (15%) (absolute risk difference, 27%; 95% CI, 17-37%). In a multivariable Poisson regression model adjusting for potential confounders, mean arterial blood pressure greater than 90 mm Hg was associated with good neurologic function (adjusted relative risk, 2.46; 95% CI; 2.09-2.88). Over ascending ranges of mean arterial blood pressure, there was a dose-response increase in probability of good neurologic outcome, with mean arterial blood pressure greater than 110 mm Hg having the strongest association (adjusted relative risk, 2.97; 95% CI, 1.86-4.76)., Conclusions: Elevated blood pressure during the initial 6 hours after resuscitation from cardiac arrest was independently associated with good neurologic function at hospital discharge. Further investigation is warranted to determine if targeting an elevated mean arterial blood pressure would improve neurologic outcome after cardiac arrest.

Background: Syncope is a common presentation in the emergency department (ED). The differential diagnosis is long and includes benign conditions as well as acute life threats, such as dysrhythmias or pulmonary embolism., Objective: The specific goals of this review are twofold: 1) to define the diagnostic utility of orthostatic vital signs (OVS) as a test for orthostatic syncope, and 2) to determine whether OVS help diagnose or exclude life-threatening causes of syncope in ED patients., Methods: Three prospective cohort studies plus 2017 national guidelines for syncope management were identified, reviewed, and critically appraised., Results: This literature review found that orthostatic hypotension is common among ED patients with syncope and is often diagnosed as the cause of syncope., Conclusions: OVS measurements do not, in isolation, reliably diagnose or exclude orthostatic syncope, nor do they appear to have value in ruling out life-threatening causes of syncope., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Studies examining the association between hyperoxia exposure after resuscitation from cardiac arrest and clinical outcomes have reported conflicting results. Our objective was to test the hypothesis that early postresuscitation hyperoxia is associated with poor neurological outcome., Methods: This was a multicenter prospective cohort study. We included adult patients with cardiac arrest who were mechanically ventilated and received targeted temperature management after return of spontaneous circulation. We excluded patients with cardiac arrest caused by trauma or sepsis. Per protocol, partial pressure of arterial oxygen (Pao 2 ) was measured at 1 and 6 hours after return of spontaneous circulation. Hyperoxia was defined as a Pao 2 >300 mm Hg during the initial 6 hours after return of spontaneous circulation. The primary outcome was poor neurological function at hospital discharge, defined as a modified Rankin Scale score >3. Multivariable generalized linear regression with a log link was used to test the association between Pao 2 and poor neurological outcome. To assess whether there was an association between other supranormal Pao 2 levels and poor neurological outcome, we used other Pao 2 cut points to define hyperoxia (ie, 100, 150, 200, 250, 350, 400 mm Hg)., Results: Of the 280 patients included, 105 (38%) had exposure to hyperoxia. Poor neurological function at hospital discharge occurred in 70% of patients in the entire cohort and in 77% versus 65% among patients with versus without exposure to hyperoxia respectively (absolute risk difference, 12%; 95% confidence interval, 1-23). Hyperoxia was independently associated with poor neurological function (relative risk, 1.23; 95% confidence interval, 1.11-1.35). On multivariable analysis, a 1-hour-longer duration of hyperoxia exposure was associated with a 3% increase in risk of poor neurological outcome (relative risk, 1.03; 95% confidence interval, 1.02-1.05). We found that the association with poor neurological outcome began at ≥300 mm Hg., Conclusions: Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge., (© 2018 American Heart Association, Inc.)

Acute heart failure (AHF) patients rarely present complaining of 'acute heart failure.' Rather, they initially present to the emergency department (ED) with a myriad of chief complaints, symptoms, and physical exam findings. Such heterogeneity prompts an initially broad differential diagnosis; securing the correct diagnosis can be challenging. Although AHF may be the ultimate diagnosis, the precipitant of decompensation must also be sought and addressed. For those AHF patients who present in respiratory or circulatory failure requiring immediate stabilization, treatment begins even while the diagnosis is uncertain. The initial diagnostic workup consists of a thorough history and exam (with a particular focus on the cause of decompensation), an EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography performed by a qualified clinician or technologist. We recommend initial treatment be guided by presenting phenotype. Hypertensive patients, particularly those in severe distress and markedly elevated blood pressure, should be treated aggressively with vasodilators, most commonly nitroglycerin. Normotensive patients generally require significant diuresis with intravenous loop diuretics. A small minority of patients present with hypotension or circulatory collapse. These patients are the most difficult to manage and require careful assessment of intra- and extra-vascular volume status. After stabilization, diagnosis, and management, most ED patients with AHF in the United States (US) are admitted. While this is understandable, it may be unnecessary. Ongoing research to improve diagnosis, initial treatment, risk stratification, and disposition may help ease the tremendous public health burden of AHF., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Acute heart failure (AHF) is a common presentation in the Emergency Department (ED), and most patients are admitted to the hospital. Identification of patients with AHF who have a low risk of adverse events and are suitable for discharge from the ED is difficult, and an objective tool would be useful., Methods: The highly sensitive Troponin T Rules Out Acute Cardiac Insufficiency Trial (TACIT) will enroll ED patients being treated for AHF. Patients will undergo standard ED evaluation and treatment. High-sensitivity troponin T (hsTnT) will be drawn at the time of enrollment and 3 hours after the initial draw. The initial hsTnT draw will be no more than 3 hours after initiation of therapy for AHF (vasodilator, loop diuretic, noninvasive ventilation). Treating clinicians will be blinded to hsTnT results. We will assess whether hsTnT, as a single measurement or in series, can accurately predict patients at low risk of short-term adverse events., Conclusion: TACIT will explore the value of hsTnT measurements in isolation, or in combination with other markers of disease severity, for the identification of ED patients with AHF who are at low risk of short-term adverse events., Competing Interests: Disclosure Mette Cole receives research support from Novartis and Roche Diagnostics. Karen Miller receives research support from NIH, PCORI, Novartis, Roche, and Trinity Biotech. Peter S Pang is or has been in the last 1 year a consultant for BMS, Janssen, Medtronic, Novartis, Trevena, scPharmaceuticals, Roche Diagnostics, and Relypsa. Sean P Collins is a consultant for Trevena, Cardiorentis, Novartis, Siemens, and Cardioxyl. Phillip Levy is a consultant for Janssen, Medtronic, The Medicines Company, Novartis, Trevena, Cardiorentis, Siemens, Roche Diagnostics, ZS Pharma, and Apex Innovations. Gregory J Fermann is a consultant for Pfizer and Janssen. The other authors report no conflicts of interest in this work.

Objective: To test whether primary emergency medical services (EMS) transport to hospitals with certain characteristics (24/7 percutaneous coronary intervention [PCI] availability, trauma center status, large [>24 bed] intensive care unit [ICU]) versus hospitals without those characteristics is associated with improved hospital survival after out-of-hospital cardiac arrest (OHCA)., Methods: This is an analysis of a prospectively collected EMS database, which archives patients with OHCA treated by a single large metropolitan EMS system. The database contains Utstein data, EMS transport data, and survival to hospital discharge. EMS providers uniformly apply advanced cardiac life support protocols to OHCA patients in the field. Patients with return of spontaneous circulation (ROSC) are transported to one of 10 hospitals in the area. If ROSC is not achieved within 30 minutes, efforts are terminated and the patient is not transported. We used multivariate logistic regression to test if receiving hospital characteristics were independently associated with survival among those transported after ROSC. We excluded patients not transported to a hospital and patients with incomplete outcome data., Results: Between January 2011 and December 2014, a total of 1,188 OHCA patients were resuscitated in the field and transported to an area hospital. After patients with missing data were excluded, 1,024 patients were included in the analysis. The mean (±SD) age was 61.1 (±17.0) years, and 57.7% were male. Of transported patients, 76% were taken to 24/7 PCI centers, 46% were taken to trauma centers, and 37% were taken to hospitals with large ICUs. There was considerable overlap in these hospital characteristics. A multivariate logistic regression model including age, sex, shockable rhythm, EMS time to scene, and dispatch complaint of cardiac arrest found that none of the hospital characteristics were independently associated with increased survival to discharge. The odds ratios (95% confidence intervals) for survival were as follows: PCI center, 1.28 (0.80 to 2.04); trauma center, 1.44 (0.73 to 2.85); and large ICU, 1.39 (0.69 to 2.80)., Conclusions: After adjusting for patient demographic data, we found no significant independent association between receiving hospital characteristics and survival to discharge among OHCA patients transported after ROSC by a single EMS agency., (© 2016 by the Society for Academic Emergency Medicine.)

Study Objective: We seek to test the efficacy of noninvasive sphenopalatine ganglion block for the treatment of acute anterior headache in the emergency department (ED) using a novel noninvasive delivery device., Methods: We conducted a randomized, double-blind, placebo-controlled trial evaluating bupivacaine anesthesia of the sphenopalatine ganglion for acute anterior or global-based headache. This study was completed in 2 large academic EDs. Bupivacaine or normal saline solution was delivered intranasally (0.3 mL per side) with the Tx360 device. Pain and nausea were measured at 0, 5, and 15 minutes by a 100-mm visual analog scale. The primary endpoint was a 50% reduction in pain at 15 minutes. Telephone follow-up assessed 24-hour pain and nausea through a 0- to 10-point verbal scale and adverse effects., Results: The median reported baseline pain in the bupivacaine group was 80 mm (IQR 66 mm - 93 mm) and 78.5 mm (IQR 64 mm to 91.75 mm) in the normal saline solution group. A 50% reduction in pain was achieved in 48.8% of the bupivacaine group (20/41 patients) versus 41.3% in the normal saline solution group (19/46 patients), for an absolute risk difference of 7.5% (95% confidence interval [CI] -13% to 27.1%). As a secondary outcome, at 24 hours, more patients in the bupivacaine group were headache free (24.7% difference; 95% CI 2.6% to 43.6%) and more were nausea free (16.9% difference; 95% CI 0.8% to 32.5%)., Conclusion: For patients with acute anterior headache, sphenopalatine ganglion block with the Tx360 device with bupivacaine did not result in a significant increase in the proportion of patients achieving a greater than or equal to 50% reduction in headache severity at 15 minutes compared with saline solution applied in the same manner., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this review was to define the effect of prehospital therapeutic hypothermia (TH) on survival and neurologic recovery in patients who have suffered out-of-hospital cardiac arrest (OHCA)., Methods: Included in this review are randomized trials assessing the effect of prehospital TH in adult patients suffering nontraumatic OHCA. Trials assessing the effect of in-hospital TH were excluded. Only studies with a low risk of bias were eligible for meta-analysis. A medical librarian searched PubMed, Ovid, EMBASE, Ovid Global Health, the Cochrane Library, Guidelines.gov, EM Association Websites, CenterWatch, IFPMA Clinical Trial Results Portal, CINAHL, ProQuest, and the Emergency Medical Abstracts Database without language restrictions. Clinicaltrials.gov was searched for unpublished studies. Bibliographies were hand searched and experts in the field were queried about other published or unpublished trials. Using standardized forms, two authors independently extracted data from all included trials. Results from high-quality trials were pooled using a random-effects model. Two authors, using the Cochrane risk of bias tool, assessed risk of bias independently., Results: Of 740 citations, six trials met inclusion criteria. Four trials were at a low risk of bias and were included in the meta-analysis (N=715 patients). Pooled analysis of these trials revealed no difference in overall survival (relative risk [RR]=0.98, 95% CI=0.79 to 1.21) or good neurologic outcome (RR=0.96, 95% CI=0.76 to 1.22) between patients randomized to prehospital TH versus standard therapy. Heterogeneity was low for both survival and neurologic outcome (I2=0)., Conclusions: Randomized trial data demonstrate no important patient benefit from prehospital initiation of TH. Pending the results of ongoing larger trials, resources dedicated to this intervention may be better spent elsewhere., (© 2014 by the Society for Academic Emergency Medicine.)

Background: The routine use of clinical decision rules and three-view plain radiography to clear the cervical spine in blunt trauma patients has been recently called into question., Clinical Question: In low-risk adult blunt trauma patients, can plain radiographs adequately exclude cervical spine injury when clinical prediction rules cannot?, Evidence Review: Four observational studies investigating the performance of plain radiographs in detecting cervical spine injury in low-risk adult blunt trauma patients were reviewed., Conclusion: The consistently poor performance of plain radiographs to rule out cervical spine injury in adult blunt trauma victims is concerning. Large, rigorously performed prospective trials focusing on low- or low/moderate-risk patients will be needed to truly define the utility of plain radiographs of the cervical spine in blunt trauma., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Acute myocardial infarction (AMI) can occur in infants. Early identification of AMI can allow for specific therapies aimed at improving patient outcomes., Objective: This article describes a case of an infant with AMI caused by a previously unreported mechanism and reviews diagnostic and therapeutic strategies for dealing with this rare disease., Case Report: We present a case of a 5-week-old infant with a fatal AMI due to a pedunculated nodule from a dysplastic aortic valve leaflet creating a ball-in-valve mechanism and occluding the left main coronary artery., Conclusion: AMI is an important diagnostic consideration in any infant presenting with signs of unexplained cardiogenic shock. Practitioners who care for children should be aware of diagnostic and therapeutic strategies for AMI in infants., (Copyright © 2013 Elsevier Inc. All rights reserved.)