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STUDY OBJECTIVE: We sought to test the effectiveness of an intervention designed to replace multivitamin infusions with alternative vitamin therapies when treating emergency department (ED) patients who present with alcohol-related illnesses. Most patients presenting to the ED with alcohol-related illnesses are not vitamin deficient, and thus the routine use of multivitamin infusions may be unnecessary. METHODS: We created an educational document that included background literature, the costs of administering multivitamin infusions, and recommended alternative vitamin therapies. We then educated each emergency physician and changed the default electronic physician order entry in EPIC to an alternative vitamin treatment. RESULTS: There were no differences in monthly alcohol-related ED visits between the preintervention (June 2008 to May 2009; mean 204; SD 17) and postintervention (June 2009 to May 2010; mean 217; SD 20) periods. A mean of 32 (SD 3.6) multivitamin infusions was administered each month preintervention; the postintervention mean was 1.1 (SD 2.7) multivitamin infusions per month. The difference was 31 multivitamin infusions per month (95% confidence interval 28 to 34 infusions). The overall percentage of patients receiving vitamin therapy after the intervention was approximately half that of those receiving multivitamin infusions before, 6.8% (SD 2.4%) versus 16% (SD 2.0%), difference 8.7% (95% confidence interval 6.8% to 11%). CONCLUSION: Our educational and order entry intervention was effective in changing physician vitamin prescribing behavior in ED patients with an alcohol-related illness. [ABSTRACT FROM AUTHOR]

Study Objective: The primary objective of our study was to compare the effectiveness of oral cephalosporins versus fluroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) for the treatment of pyelonephritis in patients discharged home from the emergency department (ED)., Methods: This was a multicenter, retrospective, observational cohort study of 11 geographically diverse US EDs. Patients aged ≥18 years diagnosed with pyelonephritis and discharged home from the ED between January 1, 2021 and October 31, 2023 were included. The primary outcome was treatment failure at 14 days defined as a composite outcome of the following: (1) recurrence of urinary symptoms, (2) repeat ED visit or hospitalization for a urinary tract infection, (3) receipt of a new antibiotic prescription for urinary tract infection. Secondary outcome was appropriateness of empiric treatment based on urine culture susceptibility., Results: Among the 851 patients who met inclusion criteria, 647 patients received a cephalosporin, and 204 patients received an Infectious Diseases Society of America guideline-endorsed first-line treatment (fluroquinolones, TMP-SMX). Overall, baseline characteristics were similar between the 2 cohorts. Rates of treatment failure were not significantly different in the cephalosporin group compared with the fluroquinolone/TMP-SMX groups (17.2% of cephalosporin vs 22.5% of fluroquinolone/TMP-SMX group, difference=5.3%, 95% confidence interval -0.118 to 0.01). After adjusting for potential confounders, cephalosporin use was not associated with treatment failure (odds ratio=0.22, 95% confidence interval 0.03 to 1.95). There was no difference in rates of appropriate empiric treatment based on urine culture susceptibility., Conclusion: Oral cephalosporins were associated with similar treatment failure rates compared with Infectious Diseases Society of America guideline-endorsed treatments for the treatment of pyelonephritis in ED patients discharged home., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Intracranial hemorrhage (ICH) is a serious complication associated with oral anticoagulant use and is associated with significant morbidity and mortality. Although anticoagulation reversal agents are utilized as standard of care, practitioners are limited in their ability to assess degree of anticoagulation reversal for direct oral anticoagulants (DOACs). There is a clinical need identify biomarkers to assess anticoagulation status in patients with DOAC-associated ICH to ensure hemostatic efficacy of anticoagulation reversal agents in the acute setting. The purpose of this study was to assess the utility of thromboelastography (TEG) to assess the impact of anticoagulation reversal in patients presenting to the emergency department (ED) with DOAC-associated ICH., Methods: We conducted a prospective, observational cohort study in adult patients presenting to the ED with acute DOAC-associated ICH. Patients were excluded if last DOAC dose was >48 hours prior to hospital arrival, if they experienced polytrauma, were pregnant, incarcerated, had a history of hepatic failure or coagulopathy, or received anticoagulation reversal with products other than prothrombin complex concentrates (PCCs). We collected baseline TEG samples from participants prior to anticoagulation reversal, as well as 30-minutes, 12-hours, and 24-hours post-reversal. TEG samples were also collected from participants who transferred to our facility after reversal at ED presentation, as well as 12- and 24-hours post-reversal., Results: Pre-reversal TEG was collected on 10 participants prior to DOAC reversal. A significant decrease in TEG R-time was observed at 30 minutes post-reversal. R-time increased at 12- and 24-hours to baseline levels. Significant changes were not observed in K-time, clot strength, maximum amplitude, or coagulation index., Conclusions: TEG R-time may be able to detect a change in anticoagulation activity of DOACs in ICH after anticoagulation reversal. R-time decreases acutely after anticoagulation reversal and rebounds at 12- and 24-hours post-reversal.

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2023. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the collective group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 6 guidelines, and 5 meta-analyses covering topics including guideline releases and updates on rapid sequence intubation in the critically ill, managing cardiac arrest or life-threatening toxicity due to poisoning, and management of major bleeding following trauma. Also discussed are ongoing controversies surrounding fluid resuscitation, time and treatment modalities for ischemic stroke, steroid use in community-acquired pneumonia, targeted blood product administration, and much more., Competing Interests: Declaration of competing interest There are two authors who declare potential competing interests. Caitlin Brown has receiving funding from Alexion/Astra Zeneca and Brian Gilbert consults and has received speakers fees from Haemonetics. All other authors have nothing to disclose relevant to this article., (Copyright © 2024. Published by Elsevier Inc.)

Disclaimer: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time., Purpose: Vasoactive medications are used during advanced cardiac life support (ACLS) to shunt oxygenated blood to vital organs and after return of spontaneous circulation (ROSC) to maintain hemodynamic goals. However, limited evidence exists to support vasoactive medication recommendations in such scenarios, and it is unknown how practices vary among emergency departments across the US., Methods: A survey questionnaire (15 questions) was electronically distributed to emergency medicine pharmacists (EMPs) in the US through various professional listservs. Demographic information, American Heart Association ACLS algorithm medication use, and use of continuous vasopressor infusions and adjunct medications following ROSC were assessed and are reported descriptively., Results: The survey was distributed to 764 EMPs, with a 23% response rate from a wide geographic distribution and 48% of respondents practicing in academic medical centers. Epinephrine dosing and administration during cardiac arrest were reported by most to be in accordance with ACLS cardiac arrest algorithms. Calcium, magnesium sulfate, and sodium bicarbonate were the most common adjunct intravenous medications given during cardiac arrest. Norepinephrine was the first-choice vasopressor (81%) for post-ROSC hypotension, while epinephrine was preferred less frequently (17%). Antibiotics and sodium bicarbonate were the most frequently administered post-ROSC adjunct medications., Conclusion: This survey of a geographically diverse group of EMPs demonstrated high ACLS algorithm adherence for epinephrine during cardiac arrest with frequent additional administration of nonalgorithm medications. Sodium bicarbonate and calcium were the most frequently administered adjunct medications during cardiac arrest, while sodium bicarbonate and antibiotics were the most frequently used adjunct medications following ROSC. Norepinephrine was the most commonly used vasopressor following ROSC., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Purpose: Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated., Methods: We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use., Findings: Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38)., Conclusions: Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities., (© 2024 The Author(s). The Journal of Rural Health published by Wiley Periodicals LLC on behalf of National Rural Health Association.)

Background: Bivalent mRNA vaccines were recommended since September 2022. However, coverage with a recent vaccine dose has been limited, and there are few robust estimates of bivalent VE against symptomatic SARS-CoV-2 infection (COVID-19). We estimated VE of a bivalent mRNA vaccine dose against COVID-19 among eligible U.S. healthcare personnel who had previously received monovalent mRNA vaccine doses., Methods: We conducted a case-control study in 22 U.S. states, and enrolled healthcare personnel with COVID-19 (case-participants) or without COVID-19 (control-participants) during September 2022-May 2023. Participants were considered eligible for a bivalent mRNA dose if they had received 2-4 monovalent (ancestral-strain) mRNA vaccine doses, and were ≥67 days after the most recent vaccine dose. We estimated VE of a bivalent mRNA dose using conditional logistic regression, accounting for matching by region and four-week calendar period. We adjusted estimates for age group, sex, race and ethnicity, educational level, underlying health conditions, community COVID-19 exposure, prior SARS-CoV-2 infection, and days since the last monovalent mRNA dose., Results: Among 3,647 healthcare personnel, 1,528 were included as case-participants and 2,119 as control-participants. Participants received their last monovalent mRNA dose a median of 404 days previously; 1,234 (33.8%) also received a bivalent mRNA dose a median of 93 days previously. Overall, VE of a bivalent dose was 34.1% (95% CI, 22.6%-43.9%) against COVID-19 and was similar by product, days since last monovalent dose, number of prior doses, age group, and presence of underlying health conditions. However, VE declined from 54.8% (95% CI, 40.7%-65.6%) after 7-59 days to 21.6% (95% CI 5.6%-34.9%) after ≥60 days., Conclusions: Bivalent mRNA COVID-19 vaccines initially conferred approximately 55% protection against COVID-19 among U.S. healthcare personnel. However, protection waned after two months. These findings indicate moderate initial protection against symptomatic SARS-CoV-2 infection by remaining up-to-date with COVID-19 vaccines., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Monica Brackney owned stock in Moderna from November 2022–April 2023 stock as part of portfolio managed by Parametric Investments Portfolio LLC. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.]., (Published by Elsevier Ltd.)

Background: Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP., Methods: This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat., Discussion: The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care., Trial Registration: ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022., (© 2023. The Author(s).)

Background: Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant., Methods: We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses >150 days previously, adjusted for multiple covariates., Results: Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants., Conclusions: A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible., Competing Interests: Potential conflicts of interest. M. B. owned stock in Moderna from November 2022 to April 2023, as part of portfolio managed by Parametric Investments Portfolio. All other authors report no potential conflicts., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2023.)

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2022. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors, with disagreements adjudicated by a third author. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 4 guidelines, and 3 meta-analyses covering topics including anticoagulant reversal, tenecteplase in acute ischemic stroke, guideline updates for heart failure and aortic aneurysm, magnesium in atrial fibrillation, sedation in mechanically ventilated patients and pain management strategies in the Emergency Department (ED), and tranexamic acid use in epistaxis and GI bleed., Competing Interests: Declaration of Competing Interest CSB has funding from Alexion/Astra Zeneca. All other authors have nothing to disclose relevant to this article., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days., Summary Background Data: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes., Methods: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations., Results: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret., Conclusions: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals., Trial Registration: Clinicaltrials.gov Identifier: NCT02800785., Competing Interests: The authors report information from Price and Faine should read the remaining authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Study Objective: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs)., Methods: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence., Results: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86)., Conclusion: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

This article highlights the most relevant emergency medicine (EM) pharmacotherapy publications indexed in 2021. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies via the GRADE system. After review of journal table of contents GRADE 1A and 1B articles were reviewed by authors. Twenty articles, 2 guidelines, 2 position papers, and 2 meta-analysis were selected for full summary. Articles included in this review highlight acute agitation management, acute appendicitis treatment, sexually transmitted infection updates, optimizing sepsis management and treatment, updates for the ideal thrombolytic agent in acute ischemic stroke and endovascular therapy candidates, indications for tranexamic acid, calicium for out of hospital cardiac arrest, optimial inotrope for cardiogenic shock, awareness during rapid sequence intubation paralysis, comparison of propofol or dexmedetomidine for sedation, treatment of cannabis hyperemsis syndrome, and prophylactic use of diphenhydramine to reduce neuroleptic side effects. Selected articles are summarized to include design, results, limitations, conclusions and impact., Competing Interests: Declaration of Competing Interest CSB: Alexion/Astra Zeneca Rare Disease. BF: Spero Therapeutics. MAR: Spero Therapeutics, advisory board for Harm Reduction Therapeutics., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence., Design: An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial., Setting: The ED of three academic medical centers., Patients: Mechanically ventilated adult patients that received neuromuscular blockers., Interventions: None., Measurements and Main Results: All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01)., Conclusions: AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed., Competing Interests: Dr. Fuller is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under award number R34HL150404. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Kollef is supported by the Barnes-Jewish Hospital Foundation. Funders played no role in the following features of the study: study design, data collection, data management, data analysis, data interpretation, writing of the article, or decision to submit the article for publication. Drs. Fuller’s, Mohr’s, and Roberts’ institutions received funding from the National Heart, Lung, and Blood Institute. Drs. Fuller, Mohr, Roberts, Faine, Drewry, and Yan received support for article research from the NIH. Dr. Drewry’s institution received funding from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: Deep sedation in the emergency department (ED) is common, increases deep sedation in the ICU, and is negatively associated with outcome. Limiting ED deep sedation may, therefore, be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment, 2) protocol implementation and practice change, and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial., Design: Pragmatic, multicenter ( n = 3), prospective before-after pilot and feasibility trial., Setting: The ED and ICUs at three medical centers., Patients: Consecutive, adult mechanically ventilation ED patients., Interventions: An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome)., Measurements and Main Results: Sedation-related data in the ED and the first 48 ICU hours were recorded. Deep sedation was defined as a Richmond Agitation-Sedation Scale of -3 to -5 or a Sedation-Agitation Scale of 1-3. One thousand three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8% ( p < 0.01). There were no concerning trends in adverse events (i.e., inadvertent extubation, device removal, and awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the preintervention group ( p < 0.01). Compared with preintervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs 18.1 (10.4)], p < 0.05 for both., Conclusions: This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes., Competing Interests: Drs. Fuller’s, Roberts’, and Mohr’s institutions received funding from the National Heart, Lung, and Blood Institute. Drs. Fuller, Roberts, Mohr, Faine, and Yan received support for article research from the National Institutes of Health. Dr. Fuller is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number R34HL150404. Dr. Kollef is supported by the Barnes-Jewish Hospital Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objective: Delirium is a common and serious brain dysfunction. The objective of our study was to test the hypothesis that opioids and benzodiazepines exposure in the emergency department (ED) is associated with delirium., Methods: This was a retrospective cohort study, including patients aged 65 years and older who were hospitalized from ED at an academic medical center from 2014 to 2017. Medication administration records were used to identify opioids and benzodiazepines given during the ED stay. Nurses used the Delirium Observation Screening Scale (DOSS) twice daily to assess delirium during hospitalization. The outcome was a positive DOSS within 1 day of ED encounter. We used logistic regression to predict the outcome of positive delirium screening by opioids and benzodiazepines., Results: A total of 7927 ED encounters that resulted in hospitalization were included in the analysis. We identified 2008 visits (25.3%) with a positive delirium screen. A total of 3304 (41.7%) received opioids, and 1801 (22.7%) received benzodiazepines. In this cohort, opioids were not associated with an increased odds of delirium (OR 1.00, 95% CI 0.87-1.15). Benzodiazepines were associated with increased odds of delirium (OR 1.37, 95% CI 1.13-1.65), as were benzodiazepines combined with opioids (OR 1.61, 95% CI 1.33-1.97)., Conclusion: In this study, the use of benzodiazepines was associated with a risk of delirium. The use of opioids did not increase the risk of delirium. Our findings imply that judicious pain management with opioids in the ED might not increase the risk of delirium., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals., Methods: A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014. The primary exposure was the number of patients in the ED at the time of ED registration, stratified by disposition (admit, discharge, or transfer) and mental health diagnosis. The primary outcome was time-to-provider evaluation, and secondary outcomes included time-to-EKG, time-to-laboratory testing, time-to-radiography, and total ED length-of-stay. Rurality was measured using the Rural-Urban Commuting Areas., Findings: A total of 5,912,368 patients were included from all 123 VHA EDs. Adjusting for acuity, new patients had longer time-to-provider when more patients were in the ED, and patients awaiting transfer for nonmental health conditions impacted time-to-provider for new patients (16.6 min delays, 95% CI: 12.3-20.7 min) more than other patient types. Rural patients saw a greater impact of crowding on care timeliness than nonrural patients (additional 5.3 min in time-to-provider per additional patient in ED, 95% CI: 4.3-6.4), and the impact of additional patients in all categories was most pronounced in the lowest-volume EDs., Conclusions: Patients seen in EDs with more crowding have small, but additive, delays in early elements of ED care, and transferring patients with nonmental health diagnoses from rural facilities were associated with the greatest impact., (© 2021 National Rural Health Association.)

Background: The prioritization of U.S. health care personnel for early receipt of messenger RNA (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (Covid-19), allowed for the evaluation of the effectiveness of these new vaccines in a real-world setting., Methods: We conducted a test-negative case-control study involving health care personnel across 25 U.S. states. Cases were defined on the basis of a positive polymerase-chain-reaction (PCR) or antigen-based test for SARS-CoV-2 and at least one Covid-19-like symptom. Controls were defined on the basis of a negative PCR test for SARS-CoV-2, regardless of symptoms, and were matched to cases according to the week of the test date and site. Using conditional logistic regression with adjustment for age, race and ethnic group, underlying conditions, and exposures to persons with Covid-19, we estimated vaccine effectiveness for partial vaccination (assessed 14 days after receipt of the first dose through 6 days after receipt of the second dose) and complete vaccination (assessed ≥7 days after receipt of the second dose)., Results: The study included 1482 case participants and 3449 control participants. Vaccine effectiveness for partial vaccination was 77.6% (95% confidence interval [CI], 70.9 to 82.7) with the BNT162b2 vaccine (Pfizer-BioNTech) and 88.9% (95% CI, 78.7 to 94.2) with the mRNA-1273 vaccine (Moderna); for complete vaccination, vaccine effectiveness was 88.8% (95% CI, 84.6 to 91.8) and 96.3% (95% CI, 91.3 to 98.4), respectively. Vaccine effectiveness was similar in subgroups defined according to age (<50 years or ≥50 years), race and ethnic group, presence of underlying conditions, and level of patient contact. Estimates of vaccine effectiveness were lower during weeks 9 through 14 than during weeks 3 through 8 after receipt of the second dose, but confidence intervals overlapped widely., Conclusions: The BNT162b2 and mRNA-1273 vaccines were highly effective under real-world conditions in preventing symptomatic Covid-19 in health care personnel, including those at risk for severe Covid-19 and those in racial and ethnic groups that have been disproportionately affected by the pandemic. (Funded by the Centers for Disease Control and Prevention.)., (Copyright © 2021 Massachusetts Medical Society.)

Objectives: To characterize prehospital air medical transport sedation practices and test the hypothesis that modifiable variables related to the monitoring and delivery of analgesia and sedation are associated with prehospital deep sedation., Design: Multicenter, retrospective cohort study., Setting: A nationwide, multicenter (approximately 130 bases) air medical transport provider., Patients: Consecutive, adult mechanically ventilated air medical transport patients treated in the prehospital environment (January 2015 to December 2020)., Interventions: None., Measurements and Main Results: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as: 1) Richmond Agitation-Sedation Scale of -3 to -5; 2) Ramsay Sedation Scale of 5 or 6; or 3) Glasgow Coma Scale of less than or equal to 9. Coma was defined as being unresponsive and based on median sedation depth: 1) Richmond Agitation-Sedation Scale of -5; 2) Ramsay of 6; or 3) Glasgow Coma Scale of 3. A total of 72,148 patients were studied. Prehospital deep sedation was observed in 63,478 patients (88.0%), and coma occurred in 42,483 patients (58.9%). Deeply sedated patients received neuromuscular blockers more frequently and were less likely to have sedation depth documented with a validated sedation depth scale (i.e., Ramsay or Richmond Agitation-Sedation Scale). After adjusting for covariates, a multivariable logistic regression model demonstrated that the use of longer-acting neuromuscular blockers (i.e., rocuronium and vecuronium) was an independent predictor of deep sedation (adjusted odds ratio, 1.28; 95% CI, 1.22-1.35; p < 0.001), while use of a validated sedation scale was associated with a lower odds of deep sedation (adjusted odds ratio, 0.29; 95% CI, 0.27-0.30; p < 0.001)., Conclusions: Deep sedation (and coma) is very common in mechanically ventilated air transport patients and associated with modifiable variables related to the monitoring and delivery of analgesia and sedation. Sedation practices in the prehospital arena and associated clinical outcomes are in need of further investigation., Competing Interests: Dr. Kollef is supported by the Barnes-Jewish Hospital Foundation. Dr. Fuller is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number R34HL150404. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. BWG, GTH, GWS reports receiving consulting fees from TerSera Therapeutics. GTH received consulting fees from Kedrion Biopharma, Inc. for participation in a human rabies immune globulin advisory board meeting and writing two manuscripts., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Throughout the COVID-19 pandemic, health care personnel (HCP) have been at high risk for exposure to SARS-CoV-2, the virus that causes COVID-19, through patient interactions and community exposure (1). The Advisory Committee on Immunization Practices recommended prioritization of HCP for COVID-19 vaccination to maintain provision of critical services and reduce spread of infection in health care settings (2). Early distribution of two mRNA COVID-19 vaccines (Pfizer-BioNTech and Moderna) to HCP allowed assessment of the effectiveness of these vaccines in a real-world setting. A test-negative case-control study is underway to evaluate mRNA COVID-19 vaccine effectiveness (VE) against symptomatic illness among HCP at 33 U.S. sites across 25 U.S. states. Interim analyses indicated that the VE of a single dose (measured 14 days after the first dose through 6 days after the second dose) was 82% (95% confidence interval [CI] = 74%-87%), adjusted for age, race/ethnicity, and underlying medical conditions. The adjusted VE of 2 doses (measured ≥7 days after the second dose) was 94% (95% CI = 87%-97%). VE of partial (1-dose) and complete (2-dose) vaccination in this population is comparable to that reported from clinical trials and recent observational studies, supporting the effectiveness of mRNA COVID-19 vaccines against symptomatic disease in adults, with strong 2-dose protection., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Deverick Anderson is the owner of Infection Control Education for Major Sports, LLC, and reports grants from the Agency for Healthcare Research and Quality and personal fees from UpToDate, outside the submitted work. Ghinwa Dumyati reports grants from Pfizer and personal fees from Roche Diagnostics. Gregory Moran reports grants from I-Mab Biopharma and BeiGene and personal fees from Light AI. Mark Steele reports personal fees from Light AI, during the conduct of the study. No other potential conflicts of interest were disclosed.

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Study Objective: The COVID-19 pandemic has resulted in widespread shortages of personal protective equipment, including N95 respirators. Although basic surgical facemasks are more commonly available, their efficacy is limited due primarily to their poor face seal. This pilot study examined the impact of a rubber band mask brace on a basic surgical mask, as determined by quantitative fit testing., Methods: Subjects wearing a basic surgical facemask and the rubber band mask brace underwent quantitative fit testing using machinery designed to certify N95 mask fit. Subjects were tested with the brace anchored behind their ears, with a paperclip behind the head, and on the side knobs of their face shields. The primary outcome measure was whether the subject passed the quantitative fit test at or above the Occupational Safety and Health Administration (OSHA)-verified standard for N95 masks., Results: Subjects (n = 11) were 54.5% female, with a median height of 70 inches (interquartile range [IQR] = 68-74), weight of 170 pounds (IQR = 145-215), and body mass index (BMI) of 24.6 (IQR = 22.2-27.2), and encompassing 5 distinct N95 mask fit types. We found that 45%, 100%, and 100% of subjects passed the quantitative fit test when the brace was anchored behind the ears, with a paperclip and on a face shield, respectively., Conclusion: Of the 11 subjects included in the analysis, across a range of body habitus and N95 mask fit types, all passed the quantitative fit test when the mask brace was anchored on either face shield or with a paperclip. This data suggests that although the brace does not create an N95 equivalent in terms of filtration, it would offer improved protection from airborne viruses when worn with a basic surgical mask., Competing Interests: The authors have no conflicts of interest to disclose., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Background : Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods : A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results : Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = -4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40-1.81) and 24% (aRR: 1.24; 95% CI: 1.10-1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7-5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions : Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

Background: Four-factor prothrombin complex concentrate (4FPCC) is used for emergent warfarin reversal, but dosing remains controversial. Following approval, further studies have evaluated a variety of fixed-dose regimens. The studies utilized lower doses as compared with package insert dosing and provided data in regard to efficacy, safety, and cost savings. Further data are needed, however, to determine which fixed-dose regimen provides optimal efficacy and safety for emergent warfarin reversal., Objectives: The purpose of this study is to evaluate the efficacy, safety, and cost-savings of a fixed-dose 4FPCC protocol., Methods: This multicentered, retrospective chart review of adult patients requiring 4FPCC for emergent warfarin reversal utilized a fixed-dose regimen of 1500 units. The 2 primary outcomes were the proportion of patients who achieved a post-4FPCC international normalized ratio (INR) of ≤1.5 and ≤2. Secondary outcomes included thrombotic events within 7 days of 4FPCC administration and survival to discharge. A cost analysis was also performed to identify potential cost savings., Results: Of the 64 patients included, 44 (68.8%) achieved a post-4FPCC INR ≤1.5, and 61 (95.3%) achieved a post-4FPCC INR ≤2.0. No thrombotic events were reported; 55 (85.9%) patients survived to hospital discharge. More than $1000 was saved per patient via utilization of the fixed-dose protocol., Conclusion and Relevance: A fixed-dose of 1500 units of 4FPCC successfully achieved a target INR of ≤1.5 in the majority of patients and resulted in no thrombotic events. This study adds to the data evaluating alternative 4FPCC dosing regimens in comparison to package insert recommended dosing.

Purpose: Rural emergency department (ED) patients require interhospital transfer for definitive care at nearly 6 times the national rate, yet transfer decision-making is variable. The goal of this study was to understand patient experiences, preferences, and decision-making in the rural interhospital transfer process, and to measure the concordance between patient opinions and provider perceptions., Methods: Ours is a mixed methods study of patients transferred to a 711-bed Midwestern academic medical center and the emergency physicians in community hospitals. Qualitative interviews were conducted by a single research assistant with admitted patients transferred from an ED, and a corresponding survey was distributed to community emergency physicians. Standardized scenarios were posed to both groups to understand transfer priorities., Findings: Seventy-nine patients and 40 physicians participated in this study. Patients and physicians cited proximity to home, medical expertise, a personal relationship with a health care provider, health insurance, privacy concerns, and patient choice as the primary factors that influenced patient transfer priorities. Compared with patient respondents, physicians overestimated the patient-perceived importance of proximity to home (P = .015) and being cared for by a personal physician (P = .049), but they underestimated the value of receiving treatment in a comprehensive medical center (P = .002). In standardized scenarios, physicians agreed with patients in transfer preferences for conditions requiring neurosurgical consultation, but they underestimated patients' desire for transfer for pneumonia requiring mechanical ventilation., Conclusion: Patients and physicians recognize similar factors that influence patient preferences in interhospital ED transfer, but physicians may overestimate the value of nonmedical influences on decision-making priorities., (© 2015 National Rural Health Association.)

Objectives: The presence of squamous epithelial cells (SECs) has been advocated to identify urinary contamination despite a paucity of evidence supporting this practice. We sought to determine the value of using quantitative SECs as a predictor of urinalysis contamination., Methods: Retrospective cross-sectional study of adults (≥18 years old) presenting to a tertiary academic medical center who had urinalysis with microscopy and urine culture performed. Patients with missing or implausible demographic data were excluded (2.5% of total sample). The primary analysis aimed to determine an SEC threshold that predicted urine culture contamination using receiver operating characteristics (ROC) curve analysis. The a priori secondary analysis explored how demographic variables (age, sex, body mass index) may modify the SEC test performance and whether SECs impacted traditional urinalysis indicators of bacteriuria., Results: A total of 19,328 records were included. ROC curve analysis demonstrated that SEC count was a poor predictor of urine culture contamination (area under the ROC curve = 0.680, 95% confidence interval [CI] = 0.671 to 0.689). In secondary analysis, the positive likelihood ratio (LR+) of predicting bacteriuria via urinalysis among noncontaminated specimens was 4.98 (95% CI = 4.59 to 5.40) in the absence of SECs, but the LR+ fell to 2.35 (95% CI = 2.17 to 2.54) for samples with more than 8 SECs/low-powered field (lpf). In an independent validation cohort, urinalysis samples with fewer than 8 SECs/lpf predicted bacteriuria better (sensitivity = 75%, specificity = 84%) than samples with more than 8 SECs/lpf (sensitivity = 86%, specificity = 70%; diagnostic odds ratio = 17.5 [14.9 to 20.7] vs. 8.7 [7.3 to 10.5])., Conclusions: Squamous epithelial cells are a poor predictor of urine culture contamination, but may predict poor predictive performance of traditional urinalysis measures., (© 2016 by the Society for Academic Emergency Medicine.)

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization., Materials and Methods: Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services., Results: Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group., Conclusions: The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: The emergency department (ED) plays a critical role in the management of life-threatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate. The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients., Methods: Retrospective before-after cohort study of all patients (n=278) treated with vancomycin in a 60,000-visit Midwestern academic ED (March 2008 and April 2011) and admitted to an intensive care unit. The primary outcome was the proportion of vancomycin doses defined as "appropriate" based on recorded actual body weight. We also evaluated secondary outcomes of mortality and length of stay., Results: The EMR dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p<0.001) and a 10.3% absolute improvement in first-dose appropriateness (34.3% vs. 24.0%, p=0.07). After controlling for age, gender, methicillin-resistant staphylococcus aureus infection, and Acute Physiology and Chronic Health Evaluation II score, 28-day in-hospital mortality (odds ratio OR 1.72; 95% CI [0.76-3.88], p=0.12) was not affected., Conclusion: A computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.

Toxicology testing of fatally injured workers is not routinely conducted. We completed a case-series study of 2005-2009 occupational fatalities captured by Iowa's Fatality Assessment and Control Evaluation (FACE) Program. The goals of our research were to: (1) measure the proportion of FACE cases that undergo toxicology testing, and describe the factors associated with being tested, and (2) measure the rate of positive toxicology tests, the substances identified and the demographics and occupations of victims who tested positive. Case documents and toxicology laboratory reports were reviewed. There were 427 occupational deaths from 2005 to 2009. Only 69% underwent toxicology testing. Younger workers had greater odds of being tested. Among occupational groups, workers in farming, fishing and forestry had half the odds of being tested compared to other occupational groups. Of the 280 cases with toxicology tests completed, 22% (n = 61) were found to have positive toxicology testing. Commonly identified drug classes included cannabinoids and alcohols. Based on the small number of positive tests, older victims (65+ years) tested positive more frequently than younger workers. Management, business, science, arts, service and sales/office workers had proportionately more positive toxicology tests (almost 30%) compared with other workers (18-22%). These results identify an area in need of further research efforts and a potential target for injury prevention strategies.

Objective: The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED)., Methods: A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively., Results: Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia., Conclusion: The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED., (Published by Elsevier Inc.)

A quick way for a clinical pharmacist to eliminate himself or herself from "employee of the month" consideration is to mention the term medication shortage. Even with training geared toward maximizing resources, the cumulative disappearance of a plethora of medications for the treatment of nausea, vomiting, and/or primary headaches is almost too much for emergency medicine physicians to manage. With prochlorperazine, metoclopramide, promethazine, and ondansetron in increasingly short supply, it is time for the Food and Drug Administration to revisit droperidol's black box warning driven by QTc interval prolongation, given its questionable validity, and restore droperidol's place in the armamentarium of emergency medicine physicians.