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Acute psychiatric presentations account for a significant number of emergency department (ED) visits. These patients require assessment by the emergency physician and often need further evaluation by a psychiatrist, who may request routine laboratory evaluation and an electrocardiogram (ECG).Do all adult psychiatric patients need routine laboratory evaluation and an ECG?Studies retrieved included 2 prospective, observational studies and 7 retrospective studies. These studies evaluate the utility of laboratory analysis in all patients presenting a psychiatric complaint and its impact on patient management and disposition.Based upon the available literature, routine laboratory analysis and ECG for all patients presenting with a psychiatric complaint are not recommended. Clinicians should consider the individual patient, clinical situation, and comorbidities when deciding to obtain further studies such as laboratory analysis. © 2022 Elsevier Inc.

Atrial fibrillation (AF) is one of the most common dysrhythmias managed in the emergency department (ED) setting. Due to the variety of patient presentations and disease severity, most patients in the United States are admitted to the hospital.In patients who present with AF, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge?Studies retrieved included two prospective observational cohort studies and four retrospective observational studies. These studies evaluate the use of risk decision tools in predicting adverse outcomes in patients with AF.Based on the available literature, RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores demonstrate modest predictive discrimination in predicting adverse events, but further validation is recommended.

Atrial fibrillation (AF) is a common dysrhythmia associated with significant morbidity and mortality. Although many patients have stable AF, some patients can present with a rapid ventricular response (RVR). In these patients, it is important to lower their heart rate. However, there are several options available for rate control in the emergency department setting.What is the most effective agent for rate control for the patient with AF in RVR?Studies retrieved included two prospective, randomized, double-blind studies and six retrospective cohort studies. These studies provide estimates of the efficacy and safety of calcium channel blockers and β-blockers for rate control in those with AF with RVR.Based upon the available literature, diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for rate control.

Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension.This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort.Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort.Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.

Background: Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative. Clinical Question: In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge? Evidence Review: Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of –1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8–99.6%) and 44.3% (95% CI 42.7–45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9–98.8%) and specificity 22.2% (95% CI 20.7–23.8%). Conclusions: Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.

Aortic dissection (AD) is a challenging diagnosis associated with severe mortality. However, acute AD is a rare clinical entity and can be overevaluated in the emergency department. D-dimer, both alone and in combination with the Aortic Dissection Detection Risk Score (ADD-RS), has been studied as a tool to evaluate for AD.Can a negative D-dimer in low-risk patients exclude AD in the emergency department?Retrieved studies included three systematic review and meta-analyses and two prospective cohort studies. D-dimer was found to be highly sensitive for acute AD, with a sensitivity of 98.0%. The ADD-RS was also highly sensitive (95.7%) for AD. Two meta-analyses reported a combination of a negative D-dimer and ADD-RS1 to have a pooled sensitivity of 99.9% and 100% for acute aortic syndrome.Neither D-dimer nor the ADD-RS alone provides adequate sensitivity to exclude acute AD. However, a negative D-dimer combined with an ADD-RS1 is likely sufficient to rule out AD. Even with these findings, physicians must place clinical judgment above laboratory testing or scoring systems when deciding whether to pursue a diagnosis of acute AD.

Background Atraumatic subarachnoid hemorrhage (SAH) is a deadly condition that most commonly presents as acute, severe headache. Controversy exists concerning evaluation of SAH based on the time from onset of symptoms, specifically if the headache occurred > 6 h prior to patient presentation. Clinical Question Do patients undergoing evaluation for atraumatic SAH who have a negative computed tomography (CT) scan of the head obtained more than 6 h after symptom onset require a subsequent lumbar puncture to rule out the diagnosis? Evidence Review Studies retrieved included a retrospective cohort study, two prospective cohort studies, and a case-control study. These studies provide estimates of the diagnostic accuracy of head CT imaging obtained > 6 h from symptom onset and diagnostic test characteristics of subsequent lumbar puncture. Conclusion The probability of SAH above which emergency clinicians should perform a lumbar puncture is 1.0%. This threshold is essentially the same as the estimated probability of SAH in patients with a negative head CT obtained more than 6 h from symptom onset. Emergency physicians might reasonably decide to either perform or forego this procedure. Consequently, we contend that the decision whether to perform lumbar puncture in these instances is an excellent candidate for shared decision-making.

Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital].Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts.Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)].While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Background: Studies show that EMS patients are often inadvertently hyperventilated (HV), resulting in hypocapnia. In TBI, HV markedly increases mortality. We evaluated continuous prehospital ETCO2 data in intubated TBI patients. Methods: Analysis of monitor data files (Philips MRx™) from a sample of intubated TBI cases in the EPIC Study (NIH-R01NS071049). Results: Among hundreds of cases, graphical display of continuous ETCO2 from 3 subjects dramatically exemplified commonly-occurring inadvertent HV. Fig 1 shows unrecognized HV lasting nearly 15 min. Fig 2 reveals nearly 14 min of increasing ventilatory rate and progressively worsening hypocapnia. Fig 3 shows nearly 4 min of HV that ends abruptly with clear, sudden recognition and slowing of ventilatory rate that leads to restoration of normal ETCO2 in only a few breaths. The corresponding EMS patient care records (PCR) failed to document the presence, severity, and duration of HV. Conclusions: In a study emphasizing prevention of HV, subsequent evaluation of continuous ETCO2 data revealed many cases of unintentionally rapid manual ventilation and severe hypocapnia, often occurring for long periods. These findings, even in the face of explicit guideline-based training, demonstrate a clear need for routine access to continuous monitor data among intubated patients for quality improvement and in clinical studies. Review of PCRs does not reliably identify mismanagement of ventilation. Furthermore, these findings make it likely that real-time audiovisual feedback technology would improve ventilatory management by alerting providers to unidentified HV that results from the frequent distractions occurring during EMS care.

The American Board of Emergency Medicine gathers extensive background information on the Accreditation Council of Graduate Medical Education-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2022 annual report on the status of physicians training in Accreditation Council of Graduate Medical Education-accredited emergency medicine training programs in the United States.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine-sponsored residency and fellowship programs, residents and fellows training in those programs, and all fellows for whom ABEM issues subspecialty certifications. We present the 2019 annual report on the status of US emergency medicine training programs.

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.

Background: Respiratory rate (RR) is a key component in commonly-used trauma scoring systems [e.g., Revised Trauma Score (RTS), TRISS]. Imprecise documentation of RR introduces misclassification when these tools are used in trauma research. By identifying each waveform, nasal cannula end tidal CO2 (NCCO2) accurately measures RR in non-intubated patients. Objective: Evaluate the relationship between EMS-documented RR measurements in patient care records (PCRs) vs. true RR recorded by non-invasive NCCO2 monitoring in major TBI patients who were never actively ventilated. Methods: Among spontaneously-breathing, major TBI cases (moderate/severe/critical), continuous NCCO2 data (Philips MRx™) were evaluated from the EPIC Prehospital TBI Study (NIH 1R01NS071049). RR classifications for RTS/TRISS were then established for each case using both PCR-documentation and monitor data. Routine monitor data (including RR) were available to EMS providers on the display at all times during care. Results: Included: 158 cases from 7 Arizona EMS agencies [(7/13-7/17; median age 55 (range 18-94); 65% male]. The Table shows RTS/TRISS case classification by PCR and monitor RR. PCR-documented RR frequently failed to correctly classify cases: RR 29: (11/34, 32.4%), normal (67/93, 72.0%; Table). In total, PCR documentation misclassified 48.7% of cases (77/158). Conclusion: These findings identify a major contributor to inaccurate trauma scoring. Since RTS and TRISS are used widely in research, this has important implications for study enrollment, case ascertainment, confounding, and risk-adjustment in injury studies. Whenever possible, QI and research studies should utilize monitor data to identify and evaluate RR and other vitals rather than relying on PCR documentation. Future development of monitor-based, real-time feedback technology might improve trauma scoring precision and provider identification of RR abnormalities.

Background: Recent studies have shown that prehospital systolic blood pressure (SBP) is strongly associated with mortality across a remarkably wide range (far above 90 mmHg) in traumatic brain injury (TBI). Furthermore, in TBI research, trial enrollment and risk-adjustment are highly dependent upon accurate documentation of BP. Our preliminary work identified potential discrepancies between EMS-documented vs. actual measured BP. Objective: In major TBI, evaluate concordance between SBP documented in EMS patient care records (PCR) and actual, monitor-recorded SBP. Methods: A subset of major TBI cases (mod/severe/critical) in the EPIC TBI Study (NIH 1R01NS071049) were analyzed (3/13-7/18). Cases from 6 EMS agencies reporting continuous monitor data (Philips MRx™) were included. All monitor data available for this analysis were displayed and accessible to the providers during EMS care. We compared the lowest PCR-documented SBP to the monitor-recorded value in each patient. Results: Included: 210 cases (median age: 52, 67% male). In 152 cases (72%), the lowest PCR-documented SBP was exactly concordant with the monitor. When concordance was defined by a difference of ≤5 mmHg, 171 (81%) were concordant. Among the 27 cases with monitor-identified hypotension ( Conclusions: Significant disparities existed between monitor-recorded and PCR-documented SBP. PCRs failed to reflect 33% of monitor-documented hypotensive cases. It appears that ongoing care responsibilities and scene distractions may cause providers to miss important BP readings. These findings identify a potential hidden contributor to poor outcomes if hypotension goes unrecognized and untreated, rather than simply not being documented. Furthermore, case ascertainment, trial enrollment, confounding, and risk-adjustment in TBI studies may be substantially impacted when these processes are based on EMS documentation. When possible, QI and research projects should utilize monitor data to identify hypotensive patients. Development of real-time audiovisual monitor feedback technology might improve provider recognition of hypotension.

Introduction: The Prehospital TBI Guidelines (PTGs) are intended for both isolated and multisystem TBI (ITBI/MTBI). However, uncontrolled hemorrhage and potential detrimental effects of fluid resuscitation in MTBI may lead to differential effectiveness compared to ITBI. Methods: Preplanned subgroup analysis of PTG effectiveness in ITBI and MTBI from EPIC (before/after system study; 133 agencies, >11,000 trained; NIH R01NS071049). Interventions: Prevention/treatment of hypoxia, hypotension, hyperventilation. Inclusion: Barell Matrix 1; 1/07-6/15. Severity subgroups [Head Region Severity Score (HRSS; AIS equivalent)]: Moderate = 1-2; Severe = 3-4; Critical = 5-6. Definitions: ITBI: TBI with no other RSS ≥3 injury. MTBI: TBI plus non-head region RSS ≥3 injuries. Pre (P1) and post-implementation (P3) cohorts were compared using logistic regression. Results: Cases: 21,852; median age 45 (IQR 24, 66); 67% male. ITBI: 16,663 (76.3%); P1 = 11,602, P3 = 5061. MTBI: 5189 (23.7%); P1 = 3626, P3 = 1563]. Hypotension occurred much more frequently in MTBI (15.8%) than ITBI (4.5%; OR = 3.9 (3.5, 4.4); p Conclusions: PTG implementation was independently associated with improved odds of survival in severe ITBI and MTBI. Despite a rate of hypotension 4 times higher in MTBI, survival improvement was at least as strong as for ITBI. Since the MTBI cohort was much more likely to receive fluid resuscitation, these findings support the PTG recommendation for aggressive treatment of hypotension in TBI even in patients with potential ongoing hemorrhage.

The American Board of Emergency Medicine gathers extensive background information on Accreditation Council for Graduate Medical Education (ACGME)–accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2020 annual report on the status of physicians training in ACGME-accredited emergency medicine training programs in the United States.

Study objective We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. Methods The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. Results There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score–Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). Conclusion Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Objective: Little is known about End-Tidal CO 2 monitoring using nasal cannula sensors (NC-CO 2 ) in non-intubated patients. Objective: To describe the patterns of NC-CO 2 seen during the EMS care of spontaneously breathing major Traumatic Brain Injury (TBI) patients. Methods: Continuous NC-CO 2 data (Philips MRx™ monitors) were evaluated from non-intubated, major (moderate, severe, critical) TBI cases (4/13-5/17) in the EPIC TBI Study (NIH 1R01NS071049). Descriptive statistics were used to evaluate case and NC-CO 2 attributes. Results: Included were 92 cases [median age = 50 (range 10-91; 66% male)]. Median respiratory rate (RR) was >15/min in 87% of cases and >20/min in 53%. The highest median RR was 39. Sixteen cases (17%) had a median NC-CO 2 2 >50. Several common NC-CO 2 patterns emerged: 1) while the final level varied among patients, the vast majority of cases (79, 86%) attained a stable “plateau” with relatively small variation after that point; 2) ETCO 2 often “ramped up” from 2 plateaus. In 78% of the cases with normal CO 2 plateaus (35-45mmHg), these levels were maintained despite high RR and/or dramatic variations in RR. Conclusions: This initial work identifies that NC-CO 2 monitoring may provide useful information in non-intubated EMS patients. After initial “ramp up,” the vast majority achieved stable readings despite dramatic RR variations. Most patients (53%) were spontaneously hyperventilating at rates more than twice “normal.” Despite this, almost half of them (43%) had ETCO 2 plateaus that were normal/near normal throughout their course. It is unclear whether the “very low” readings ( 2 flow. Future studies comparing NC-CO 2 to measured arterial pCO 2 are needed to identify the correlation and accuracy of NC-CO 2 as a tool for evaluating ventilatory physiology.

Background: The EMS traumatic brain injury (TBI) guidelines encourage limiting prehospital intubation (ETI) to patients with profoundly depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate without ETI. Thus, EMS providers may manage many TBI patients without intubating even when they have significant alterations in LOC. Monitoring End-Tidal CO2 by placing sensors in the nares (NC-CO2) of non-intubated patients may give providers valuable information about ventilatory status and trends. Study Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI patients. Methods: Non-intubated cases from 6 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC Study (NIH 1R01NS071049) were evaluated (4/13-3/17). Glasgow Coma Scale (GCS) was available from the EMS record in call cases. Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: Results: Included were 106 cases [median age: 47 (range: 9-91), 66% male]. The Table shows the NC-CO2 patterns and comparisons across the GCS categories. In no case was there a significant difference in NC-CO2 between the better vs. worse mental status cohort. Conclusion: We believe this is the first evaluation of the association between NC-CO2 and mental status in TBI. Patients that had significant (and even profound) decreases in LOC, but whom paramedics chose not to intubate, had remarkably similar NC-CO2 patterns compared to those with normal or near-normal mental status. This may support the overall approach of limiting ETI to those with airway/ventilatory compromise or impending hypoxia as there was no evidence of increasing NC-CO2, indicative of hypercapnia, in the non-intubated patients even when they had very depressed LOC.

Introduction: The EPIC Study implemented the national EMS TBI Guidelines in a massive, statewide initiative (>11,000 providers trained, 133 agencies). While implementation was not associated with improved survival to discharge in moderate or critically-severe TBI in the primary (all-age) study, the adjusted odds of survival doubled in severe TBI and tripled in severe, intubated TBI. We now report the preplanned pediatric subgroup analysis (“EPIC4Kids”-NIH R01NS071049). Methods: Multisystem, intention-to-treat study using a before/after controlled design in patients with moderate to critically severe TBI. Interventions: Prevention/treatment of hypoxia, hypotension, and hyperventilation by EMS providers. Inclusion: Age Results: Included were 2801 cases [P1=2041 (72.9%), P3=760 (27.1%); median age 11 (IQR 2, 15); 62.9% male]. The all-severity P3 vs P1 cohort analysis yielded adjusted odds (aOR) of 1.16 (95%CI 0.697, 1.92, p=0.57) for survival. In severe TBI (P1=1405, P3=605; 80% of P3 cases), but not moderate or critical TBI, adjusted survival was significantly improved after implementation (Figure; p=0.049). Improvement in survival for those with severe, intubated TBI (P1=174, P3=44) approached significance (Fig; p=0.11). Conclusion: In the first controlled study of its kind, implementation of the EMS TBI guidelines was independently associated with a dramatic increase in adjusted survival among children with severe TBI. The aOR for survival was even larger than that of the overall (all-age) EPIC Study and supports widespread implementation of the guidelines in children.

OBJECTIVE This study was undertaken to expand on results from a 2014 study on the association between physician age and performance on the American Board of Emergency Medicine (ABEM) ConCert examination. METHODS This was a retrospective, longitudinal growth study comparing performance on the ConCert examination and physicians' ages at the time of examination. All examination attempts from 1990 to 2016 made by residency-trained physicians were eligible for inclusion. Multilevel growth models were constructed to examine the relationship between age at time of examination and performance, controlling for physician characteristics. RESULTS The study group included 15,533 examination attempts by 12,786 physicians. The mean (±SD) age of the physicians across all examination administrations was 45.02 (±5.18) years (range = 35 to 72 years). The mean (±SD) ConCert examination score across all administrations was 85.39 (±5.71; range = 51 to 100). Among first-time ConCert examination takers, older age was associated with lower examination scores (r = -0.25, p

Background The “gold standard” approach for defining an internal target volume (ITV) is using 10 gross tumor volume (GTV) phases delineated over the course of one respiratory cycle. However, different sites have adopted several alternative techniques which compress all temporal information into one CT image set to optimize work flow efficiency. The purpose of this study is to evaluate alternative target segmentation strategies with respect to the 10 phase gold standard. Methods A Quasar respiratory motion phantom was employed to simulate lung tumor movement. Utilizing 4DCT imaging, a gold standard ITV was created by merging 10 GTV time resolved image sets. Four alternative planed ITV’s were compared using free breathing (FB), average intensity projection (AIP), maximum image projection (MIP), and an augmented FB (FB-Aug) set where the ITV included structures from FB plus max-inhale/exhale image sets. Statistical analysis was performed using the Dice similarity coefficient (DSC). Seventeen patients previously treated for lung SBRT were also included in this retroactive study. Results PTV’s derived from the FB image set are the least comparable with the 10 phase benchmark (DSC = 0.740-0.408). For phantom target motion greater than 1 cm, FB and AIP ITV delineation exceeded the 10 phase benchmark by 2% or greater, whereas MIP target segmentation was found to be consistently within 2% agreement with the gold standard (DSC > 0.878). Clinically, however, the FB-Aug method proved to be most favorable for tumor movement up to 2 cm (DSC = 0.881 ± 0.056). Conclusion Our results indicate the range of tumor motion dictates the accuracy of the defined PTV with respect to the gold standard. When considering delineation efficiency relative to the 10 phase benchmark, the FB-Aug technique presents a potentially proficient and viable clinical alternative. Among various techniques used for image segmentation, a judicious balance between accuracy and efficiency is inherently required to account for tumor trajectory, range and rate of mobility.

Spanish-only speaking residents in the United States face barriers to receiving potentially life-saving 911 interventions such as Telephone -cardiopulmonary resuscitation (TCPR) instructions. Since 2015, 911 dispatchers have placed an increased emphasis on rapid identification of potential cardiac arrest. The purpose of this study was to describe the utilization and timing of the 911 system during suspected out-of-hospital cardiac arrest (OHCA) by Spanish-speaking callers in Metropolitan Phoenix, Arizona.The dataset consisted of suspected OHCA from 911 centers from October 10, 2010 through December 31, 2013. Review of audio TCPR process data included whether the need for CPR was recognized by telecommunicators, whether CPR instructions were provided, and the time elements from call receipt to initiation of compressions.A total of 3398 calls were made to 911 for suspected OHCA where CPR was indicated. A total of 39 (1.2%) were determined to have a Spanish language barrier. This averages to 18 calls per year with a Spanish language barrier during the study period, compared with 286 OHCAs expected per year among this population. The average time until telecommunicators recognized CPR need was 87.4s for the no language barrier group compared to 160.6s for the Spanish-language barrier group (p0.001).Time to CPR instructions started was significantly different between these groups (144.4s vs 231.3s, respectively) (p0.001), as was time to first compression, (174.4s vs. 290.9s, respectively) (p0.001).Our study suggests that Hispanic callers under-utilize the 911 system, and when they do call 911, there are significant delays in initiating CPR.

Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures.This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT):35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group.22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT.In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2017 annual report on the status of US emergency medicine training programs.

Background The current standards for domestic emergency medical services suggest that all patients suspected of opioid overdose be transported to the emergency department for evaluation and treatment. This includes patients who improve after naloxone administration in the field because of concerns for rebound toxicity. However, various emergency medical services systems release such patients at the scene after a 15- to 20-min observation period as long as they return to their baseline. Objectives We sought to determine if a “treat and release” clinical pathway is safe in prehospital patients with suspected opioid overdose. Results Five studies were identified and critically appraised. From a pooled total of 3875 patients who refused transport to the emergency department after an opioid overdose, three patient deaths were attributed to rebound toxicity. These results imply that a “treat and release” policy might be safe with rare complications. A close review of these studies reveals several confounding factors that make extrapolation to our population limited. Conclusion The existing literature suggests a “treat and release” policy for suspected prehospital opioid overdose might be safe, but additional research should be conducted in a prospective design.

Study objective Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination. Methods All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: 200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure Results Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death. Conclusion In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.

Introduction One of the barriers to improving cardiac arrest survival is the low rate of cardiopulmonary resuscitation (CPR) provision. Identifying this as a public health issue, many medical students often assist in training the community in CPR. However, these experiences are often short and are not associated with structured resuscitation education, limiting the student's and the community's learning. In this assessment, we identified a need and developed a curriculum, including defined goals and objectives, for an undergraduate medical education (UME) elective in CPR. Methods At an academic university environment with a strong UME program, we developed a longitudinal UME elective in CPR. The curriculum is a four-year longitudinal experience, which satisfies two weeks of their fourth year of medical school. The curriculum includes structured training over the four-year period in the fundamentals of resuscitation science (through didactics, journal club, and hands-on skills training), in addition to structured community CPR teaching. The elective concludes with a final hands-on summative appraisal. Data concerning medical student program enrollment, CPR training events conducted, venues of events, and the number of individuals trained were collected over a five-year period. Results The CPR elective was developed with clear goals and objectives based on identified needs. Over the five-year period, 186 medical students completed the CPR longitudinal elective, accounting for 8.4% of the total medical student population. Students completed curriculum requirements and satisfied both didactic and hands-on training with all students passing the final summative appraisal. Over the five-year period, students trained 8,694 people in bystander CPR. The summative evaluation had a 100% pass rate. Conclusion Implementation of a longitudinal CPR elective improved resuscitation science education for medical students and fostered increased community CPR training. This describes one local effort to improve resuscitation science education and training for medical students. Further work will need to be done to evaluate the impact of UME resuscitation curricula on medical student career choice and resuscitation outcomes.

Background: Physicians' adherence to guideline-recommended therapy is associated with short-term clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). However, its impact on longer-term outcomes is poorly documented. Here, we present results from the 18-month follow-up of the QUALIFY registry. Methods and results: Data at 18 months were available for 6118 ambulatory HFrEF patients from this international prospective observational survey. Adherence was measured as a continuous variable, ranging from 0 to 1, and was assessed for five classes of recommended HF medications and dosages. Most deaths were cardiovascular (CV) (228/394) and HF-related (191/394) and the same was true for unplanned hospitalizations (1175 CV and 861 HF-related hospitalizations, out of a total of 1541). According to univariable analysis, CV and HF deaths were significantly associated with physician adherence to guidelines. In multivariable analysis, HF death was associated with adherence level [subdistribution hazard ratio (SHR) 0.93, 95% confidence interval (CI) 0.87–0.99 per 0.1 unit adherence level increase; P = 0.034] as was composite of HF hospitalization or CV death (SHR 0.97, 95% CI 0.94–0.99 per 0.1 unit adherence level increase; P = 0.043), whereas unplanned all-cause, CV or HF hospitalizations were not (all-cause: SHR 0.99, 95% CI 0.9–1.02; CV: SHR 0.98, 95% CI 0.96–1.01; and HF: SHR 0.99, 95% CI 0.96–1.02 per 0.1 unit change in adherence score; P = 0.52, P = 0.2, and P = 0.4, respectively). Conclusion: These results suggest that physicians' adherence to guideline-recommended HF therapies is associated with improved outcomes in HFrEF. Practical strategies should be established to improve physicians' adherence to guidelines. © 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiology

Background: Traumatic brain injury (TBI) studies with extensive prehospital data linked to trauma center (TC) outcomes have been small. Thus, risk adjusters like age and systolic BP have been treated dichotomously (e.g. age ≥55, SBP Hypothesis: The interactions between age, SBP, and mortality are neither simple nor dichotomous. Methods and Inclusion: Major TBI cases, age ≥10, in EPIC (NIH 1R01NS071049) before TBI guideline implementation (1/07-3/14). Logistic regression was used to associate death with age and lowest EMS SBP, adjusted for confounders, and fitted nonparametrically using penalized thin plate regression splines through the generalized additive model. Results: Included were 13,435 cases (Excl: 6.2% missing data; Med. age 46; 67.8% male). The Figure shows 3D planar images of the associations between adjusted risk of death (vertical axis), age and SBP. Fig A reveals: 1) there is no “hypotension threshold” below 120 mmHg at any age and this inflection point increases to 135 in older adults; 2) the optimal SBP vs outcome “valley” is very broad (e.g. ~120-180 in the young) and increases with age (~135-190 in the elderly). Figs B/C reveal: 1) mortality increases across the entire spectrum of age, 2) in hypotensive cases (SBP linearly with increasing age, 3) in non -hypotensive patients, the adjusted risk of death increases much more rapidly after age 40. Conclusion: Due to the small size of extant EMS studies, the evidence supporting parameters in triage guidelines (e.g. “older adults”) and EMS treatment guidelines (e.g. SBP

Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitoring of intubated patients in many emergency care settings, including EMS. Previous work has explored the use of ETCO2 monitoring in non-intubated patients with sensors placed in the nares. However, nothing is known about the effect of passive oxygen delivery [nasal cannula (NC) or non-rebreather mask (NRB)] on ETCO2 measurement. Objective: To compare ETCO2 measurements in non-intubated Traumatic Brain Injury (TBI) patients receiving O2 via NC vs NRB in the prehospital setting. Methods: A subset of major TBI cases (CDC Barell Matrix Type-1) in the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS-1R01NS071049; ClinicalTrials.gov-NCT01339702) were evaluated 4/13-3/17). Non-intubated cases from 6 EMS agencies providing monitor data (Philips MRx) were included when continuous ETCO2 data were available. Statistics: Two-tailed t test, α = 0.05. Results: The 104 included cases had median age of 50.5 (range: 9-91; male: 67%). 39 (37.5%) received O2 via NC and 65 (62.5%) via NRB. Mean ETCO2: NC cases: 27.7 mmHg (95% CI: 25.7, 29.8); NRB: 30.0 (28.1, 31.8; p=0.132). There were also no significant differences among the mean lowest recorded values (p=0.449) or the mean highest values (p=0.275). Conclusion: We believe this is the first report comparing ETCO2 values based upon the method of passive O2 delivery in non-intubated patients. The minor differences between NC vs NRB-oxygenated patients was neither statistically nor clinically significant. This is surprising since: 1) the O2 flow rates and 2) the open-air (NC) vs mask (NRB) delivery methods are so dramatically different. Future study is needed to identify the clinical implications of using noninvasive ETCO2 measurement as a tool for monitoring ventilatory status and changes in non-intubated TBI (and other) patients.

Background: In hospital-based studies, hypotension (HT, SBP Hypothesis: Prehospital HT is associated with differential effects in MTBI and ITBI and these effects are influenced by the severity of primary brain injury. Methods: Inclusion: TBI cases in the EPIC Study (NIH 1R01NS071049) before TBI guideline implementation (1/07-3/14). ITBI: Major TBI cases (CDC Barell Matrix Type 1) that had no injury with ICD9-based Regional Severity Score [RSS (AIS equivalent)] ≥3 in any other body region. MTBI: Type 1 TBI plus at least one non-head region injury with RSS ≥3. Results: Included were 13,435 cases [Excl: age Conclusion: Among major TBI patients with prehospital HT, those with MTBI were much more likely to die than those with ITBI. However, this association varied dramatically with TBI severity. In mod/severe TBI cases with HT, MTBI mortality was 2.4 times higher than in ITBI. In contrast, in very/extremely severe TBI with HT, there was no identifiable mortality difference. Thus, in cases with substantial potential to survive the primary brain injury (mod/severe), outcome is markedly worse in patients with multisystem injuries. However, in very/extremely severe TBI, non-head region injuries have no apparent association with mortality. This may be because the TBI is the primary factor leading to death in these cases. The main EPIC study is evaluating whether this severity-based difference in “effect” has implications for TBI guideline treatment effectiveness.

Background: End-Tidal CO2 (ETCO2) monitoring is valuable in the management of traumatic brain injury (TBI). In intubated patients it helps prevent hyper/over-ventilation. In non-intubated patients, placing a sensor in the nares allows accurate monitoring of respiratory rate and has other promising uses (e.g. monitoring ETCO2 trends in worsening TBI, COPD, etc). Study Objective: To identify how accurately EMS providers document ETCO2, we compared the values recorded in EMS patient care records (PCR) to monitor data in non-intubated TBI patients. Methods: Cases from 6 EMS agencies reporting continuous monitor data (Philips MRx) in the EPIC Study (NIH 1R01NS071049) were evaluated (4/13-3/17). All ETCO2 data available for this post-hoc review were displayed and accessible to the EMS providers during care. Concordance was defined in two ways (for both highest and lowest ETCO2): ≤5 and ≤3 mmHg difference between the monitor data and PCR-documented values. Results: 106 cases were included [median age: 47 (range: 9-91), 66% male]. The figure shows concordance between PCR documentation and monitor data for both the lowest and highest recorded ETCO2 values. Conclusion: The highest PCR-recorded vs monitor ETCO2 values had excellent concordance for a difference ≤5 mmHg (85.9%) and it was good (76.4%) even when defined at the limits of instrument precision (≤3 for ETCO2 compared to actual pCO2). However, for lowest ETCO2, concordance was very poor (only 42.5% for ≤5). The failure to accurately document low ETCO2 in a “passive-ventilation” setting may also have significant implications for improving ventilatory care among intubated patients because identifying and correcting hypocapnia/hyperventilation in actively-ventilated cases is extraordinarily important. The low concordance rates may be due to the emphasis on discreet, intermittent vital sign documentation rather than ongoing identification and documentation of significant ETCO2 variation.