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Restraints are often utilized in the emergency department (ED) to prevent patients from injuring themselves or others while managing their agitation in order to deliver appropriate medical care. Chemical and physical restraints are ordered at the discretion of the medical provider and typically employed after reasonable verbal de-escalation has been attempted. While health inequities and racial bias in medicine and healthcare have been well-established, information on the differences in the selection and use of restraints by race and ethnicity are scarce.This retrospective cohort study utilized national data from HCA Healthcare ED and inpatient database with patient visits from 2016 to 2019 to evaluate the relationships between race and ethnicity and the utilization of restraints in the ED. Associations are reported using linear and logistic regression analyses.The study population included 12,229 unique ED admissions for patients 16 and older with diagnoses of aggression or agitation who had either chemical or physical restraints used. There was no statistically significant difference when comparing Black or other race to White patients and the type of restraint used. Hispanic patients received 0.206 fewer doses of chemical restraints compared to White patients (p = 0.008, 95% C.I. [-0.359, -0.053]) and were slightly less likely to receive physical restraints compared with White patients (p = 0.044, 95% C.I. [0.467, 0.989]), but there was no difference between use of physical restraint and Black or other patients compared to White patients.In this national sample of agitated and/or aggressive ED patients who were restrained, Hispanic patients were slightly less likely to receive physical restraints and received fewer doses of chemical restraints than White patients. There were no differences between Black or other patients compared to White patients in restraint type, number of doses of chemical restraint or time to application of either restraint type. This suggests that physicians apply the use of chemical restraints to agitated and aggressive ED patients based on factors that are not associated with race and ethnicity.

Background In this paper, the authors review the safety and practicality of elastomeric respirators for protecting themselves and others from the novel coronavirus or COVID-19. They also describe the safe donning and doffing procedures for this protective gear. Main text Due to the shortage of personal protective equipment (PPE), the CDC has recommended ways to conserve disposable N95 masks, including re-use and extended use, and reserving N95 masks for aerosol-generating procedures. However, these were never made to be re-used. Although the modes of transmission of COVID-19 are not fully understood, based on what we know about severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), droplets and aerosolized droplets contribute to the spread of this virus. More evidence from Wuhan, China, has demonstrated that COVID-19 viral particles are aerosolized and found in higher concentrations in rooms where PPE is being removed. Thus, it is best for all healthcare providers to have full aerosol protection. Conclusion Given the shortage of PPE for aerosols, it is logical to utilize reusable elastomeric respirators with filter efficiency of 95% or higher. A single elastomeric respirator may replace hundreds to thousands of new disposable N95 masks.

Objective We aimed to assess physicians’ perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. Methods This was a cross-sectional survey study of American emergency medicine (EM) physicians with a self-administered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs’ listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. Results There were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). Conclusion Barriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.

We report the case of a 77-year-old male with no prior history of stroke who came in as a stroke alert for right facial droop and speech slurring, but upon presentation he had decreased responsiveness. Initial imaging for stroke was negative. Laboratory evaluation revealed no abnormalities. As lumbar puncture was about to be performed, the patient had a sudden resolution of symptoms, became responsive, and started answering questions. Magnetic resonance imaging (MRI) revealed small acute infarcts in the bilateral thalami and adjacent central aspect of the midbrain, right larger than the left. General decreased responsiveness needs to be considered in the differential diagnosis of stroke.

Study Objectives: To study the impact of COVID-19 hospitalizations on patients from differing ethnic and racial groups. Study Design and Methods: This is an IRB-exempt observational cohort study of de-identified patient data obtained from our central billing system comprising greater than 8.6 million emergency visits annually in over 175 United States hospitals. Inclusion criteria were adults aged 18 years and older, a presentation to one of our hospital emergency departments, and an admission for COVID-19 infection. Outcome variables were length of stay, in-hospital mortality, disease severity, and discharge disposition. Discharge disposition was further categorized into home, skilled nursing facility, hospice. Outcomes were stratified by racial groups: White, Black, Hispanic and Other. Statistical analysis consisted of summary statistics (distributions) with medians and interquartile ranges reported for non-normally distributed variables. Linear regression analyses determined factors predictive of outcome. A p-value of

This study examines the relationship between serial serum lactate levels and in-hospital mortality in an adult cohort of emergency department patients with severe sepsis or septic shock. Of the 164 patients in the cohort, 130 also got three-hour lactate in addition to the initial one. The median initial lactate was 3.01 (interquartile range [IQR]: 1.71-4.62). The median repeat lactate was 2.58 (IQR: 1.4-3.9). The in-hospital death rate was 23% for men and 29% for women. The delta lactate was significantly higher in women (P=0.0070), driven by a lower initial lactate (P=0.0277). In a multivariate regression model controlled for age and gender, a statistically significant correlation was noted between an increase in the delta lactate and in-hospital death (P=0.0323; R2=11.3%). The results of this single-center study suggest that an increase in serum lactic acid is significantly associated with higher in-hospital death.

Although foreign body ingestions are less common in adults than children, when they do occur, it is often due to a fish or chicken bone. The authors present a case of a fish bone ingestion, and highlight its appearance on imaging.

This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

Background Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques. Objective We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses. Discussion We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate. Conclusion This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of “chronic refractory ITP” is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.

Background The authors present seven winning strategies for maintaining a rich academic environment for learners while working in a busy emergency department with expected productivity metrics. Methods This is a descriptive paper based on existing literature and on the authors’ experience. Results Winning strategies to improve ED throughput while also supporting the mission of medical education and improving the learning environment for students include the following: (1) attending first, (2) provider in triage, (3) mobile workstations, (4) patient education, (5) bedside patient presentations, (6) dedicated teaching resident, and (7) thoughtful scheduling. Conclusions The authors present seven practical strategies that are portable to many settings.

Corneal abrasions can have potentially sight-threatening consequences if not accurately diagnosed and managed appropriately in the acute period. Simple corneal abrasions can be managed with antibiotic and tetanus prophylaxis, analgesia, and next-day follow up with ophthalmology. However, if there is any suspicion for penetrating eye injury, corneal ulcer, a sight-threatening infection such as bacterial keratitis, or ophthalmic zoster, an emergent referral is imperative. In this report, we present a case of classic corneal abrasion and discuss the acute management of this common problem.

Mucinous cystadenomas are a common benign neoplasm of the ovaries that can grow much larger than other adnexal masses. We report a case of a 28-year-old female who presented with one month of increasing abdominal distension and upper abdominal pain; she was found to have a 30-centimeter (cm) adnexal mass. Pathology showed a benign mucinous cystadenoma with no evidence of malignancy. The authors discuss the initial evaluation and management of adnexal masses in general, as the variety of etiologies and severity can make this a difficult task. The characteristics of different adnexal masses and the indications for gynecologic consultation and surgery are also discussed.

Study Objectives: With the dawn of the COVID-19 pandemic and the need for enhanced social distancing measures, telemedicine has become an integral part of emergency medicine Medical schools have started to integrate telemedicine training into their curricula, but there are few reports of telemedicine training in GME programs The primary objective of this study was to examine current emergency medicine resident knowledge of telemedicine, expose residents to standardized telemedicine patients virtually, and analyze the effectiveness of telemedicine training on completing a successful encounter Methods: Seventeen emergency medicine residents first underwent a virtual standardized telemedicine encounter using the ZoomTM application without prior training in telemedicine Standardized patients were queried on resident success during this untrained encounter using a survey with aspects of a successful encounter The following session with sixteen of those 17 residents, involved a lecture by a telemedicine physician with years of experience on the fundamentals of a successful encounter, as well as pre-reading materials on the topic After this intervention, sixteen residents underwent a repeat virtual encounter, with standardized patients responding to the same questions as the pre-training Residents also underwent a post-survey on their experiences Results: Standardized patients evaluated 17 emergency residents before telemedicine training, and 16 of those 17 residents after telemedicine training with a 13-question survey focused on aspects of a successful telemedicine interview Statistically significant differences were noted on aspects of the encounter related to telemedicine when analyzing pre- and post-training data and using a Z test for proportions: obtaining informed consent (0% vs 61%, p = 0 00012), asking about privacy in the patient’s environment (6% vs 87%, p

The International Consensus Definition for Sepsis and Septic Shock Task Force has recently developed new methods to determine whether a patient is at risk for end organ failure after he has been suspected to have sepsis. One of the newest measures developed is a quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), and it is used to identify patients who are at risk of sepsis outside the intensive care unit. The systemic inflammatory response syndrome (SIRS) score has previously been the standard for determining a patient’s sepsis risk and prognosis for future mortality. With the development of these new tools, it is imperative to compare qSOFA to SIRS in order to determine which method is best and under which circumstances. We conclude that according to evidence currently available, qSOFA has limited use for patients in the intensive care unit at the time of evaluation for predicting mortality and organ dysfunction. Furthermore, qSOFA outranks SIRS for patients in the emergency department except for SIRS delivering positive results more quickly.

Objective The objective of this study was to improve sepsis bundle compliance via an educational intervention in our emergency department (ED). Methods This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. Data were collected for 30 consecutive days to compare sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance. The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers and 2) there was a daily email blast for one month with “sepsis facts.” These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis. Results The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399). We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived that our intervention was helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question “Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?” 70% answered agree or strongly agree. To the question “Were you more likely to order the sepsis bundle after receiving the daily "Sepsis Facts"?” 29% were neutral while 59% answered agree or strongly agree. Finally, to the question “Did you feel the sepsis cards and "sepsis facts" help you improve the care of Septic patients in the emergency department?” 76% answered agree or strongly agree. Conclusion Sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department.

Chest pain in acute coronary syndrome (ACS) unresponsive to nitrates is routinely treated by intravenous (IV) morphine. In the past two decades, several studies have emerged, suggesting poorer outcomes in patients receiving this treatment; however, morphine remains the drug of choice for these patients as per the American College of Cardiology/American Heart Association guidelines on ACS management. The results of various studies that examined the impact of morphine on myocardial infarct size, antiplatelet therapy absorption time, and patient mortality are discussed. There is mounting evidence suggesting that morphine may increase adverse events in ACS patients, therefore, the development of more precise criteria for IV morphine administration in ACS patients is needed.

Deciding on proper medication administration for the traumatic brain injury (TBI) patient undergoing intubation can be daunting and confusing. Pretreatment with lidocaine and/or vecuronium is no longer recommended; however, high-dose fentanyl can be utilized to help blunt the sympathetic stimulation of intubation. Induction with etomidate is recommended; however, ketamine can be considered in the proper patient population, such as those with hypotension. Paralysis can be performed with either succinylcholine or rocuronium, with the caveat that rocuronium can lead to delays in proper neurological examinations due to prolonged paralysis. Recommendations for post-intubation continuous sedation medications include a combination propofol and fentanyl in the normotensive/hypertensive patient population. A combination midazolam and fentanyl or ketamine alone can be considered in the hypotensive patient.

A pulmonary embolism (PE) is an acute life-threatening respiratory event that results in upwards of 200,000 deaths per year in the United States. While anticoagulation is currently the standard of treatment for PEs, there is increasing evidence to suggest that in certain cases anticoagulation in combination with thrombolytic therapy may improve patient outcomes and reduce mortality. This article aims to compare the effects of combined intervention with thrombolytic therapy and anticoagulation to the effects of anticoagulation alone in patients with submassive PEs in terms of various outcome measures, including but not limited to: mortality, hemodynamic status, length of hospital stay, and safety. The methodology consisted of the critical appraisal of the primary literature articles pertaining to intervention with thrombolytic agents in cases of a submassive or intermediate risk PE, including a discussion of each study’s strengths and limitations. Ultimately, this review found that the use of thrombolytic agents in conjunction with anticoagulants has been associated with decreased hemodynamic decompensation and decreased length of hospital stay, with no change in mortality outcomes, at a cost of increased rate of bleeding and stroke. The use of thrombolytic agents with anticoagulants may be warranted in a specific subset of patients, but clinicians should consider the potential benefits and harms of this intervention.

A 57-year-old female with past medical history of atrial fibrillation, diabetes mellitus, hyperlipidemia, and hypertension presents to the emergency department for a brief episode of painless vision loss in her left eye shortly before arrival. She describes the vision loss as a curtain pulled over the eye with vision returning spontaneously minutes later. She denies trauma to the eye, headache, fever, history of migraines, or prior similar episodes.

Posttraumatic cerebral sinus thrombosis is an uncommon disease in children that is rarely seen in the setting of a closed head injury. We report a 6-year-old boy who developed cerebral sinus thrombosis after an apparent minor head injury. The clinical presentation, neuroimaging findings, and treatment strategies are discussed. Serial neurological evaluation and close observation are important, and the decision for anticoagulation should be carefully considered with hematological consultants. Language: en