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Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support.We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED.A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold.High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

Background The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. Objective Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. Methods We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. Results There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. Conclusions This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Introduction Outside the United States, bromelain-based enzymatic debridement (BBED) has become an effective tool for removal of burn eschar. BBED can be performed at bedside and allows for complete eschar removal with maximal dermal preservation and markedly reduced blood loss. It may also decrease the need for autografting or the amount of autograft required. A primary concern with BBED is that it is a painful procedure requiring appropriate analgesia. Experience with BBED in the U.S. has been gained through a multicenter phase 3 clinical trial (DETECT) and an expanded access treatment protocol (NEXT). In this retrospective study, we describe our experience using BBED, with particular focus on pain management. Methods A retrospective review was conducted on 29 adult burn patients enrolled in the DETECT or NEXT trials who underwent BBED of acute deep partial- and full-thickness thermal burn wounds at a major burn center between November 2016 and July 2022. Patient demographics and procedural characteristics, including pain management strategies and Numerical Pain Rating Scale (NPRS) scores before, during, and after debridement, were analyzed and described. Results Twenty-nine patients with an average age of 41.2 years (SD=17.8, range 18-72) and an average TBSA of 6.3% (SD=5.6, range 1-24.5) underwent a total of 29 BBED. For pain control during debridement, 6 patients required conscious sedation (CS), 7 a regional block (RB), 5 a local block (LB), and 9 only IV and oral (IVPO) medications. Two patients were intubated and sedated prior to the procedure. No patient required additional BBED treatment and all patients achieved >95% eschar removal. The average NPRS pain score 24 hours before treatment, during treatment, and 24 hours after treatment was 4.0, 4.6, & 4.4, respectively (P=0.65). Sixteen patients (55%) healed without the need for autografting. The average number of days from debridement to wound closure for all patients was 34.9 days (SD=11.9) and for patients who underwent autografting was 40.1 days (SD=12.3). Conclusions With appropriate analgesia, it is possible to perform BBED of acute deep partial- and full-thickness thermal burns without significant changes in patient-reported pain scores. Prior to debridement, it is critical to establish procedure logistics and reasonable patient expectations. Applicability of Research to Practice The authors review their experience controlling pain associated with BBED.

When the domestic and international travel restrictions resulting from the COVID-19 pandemic made face-to-face training and professional development activities impossible, organizations needed to shift rapidly to a virtual format. One such organization, the DACUM International Training Center at The Ohio State University's Center on Education and Training for Employment, was forced to reimagine its five-day, in-person DACUM Institute—a workshop with a 35-year history of training human resources and learning and development professionals in the DACUM method of job analysis. This chapter examines the opportunities presented by and the challenges inherent in deconstructing this face-to-face experience and reimagining it as a virtual one, the DACUM Virtual Institute. This online program, a mix of synchronous and asynchronous learning activities, puts into practice learning design methodologies and learner experience design principles to capture the essential components of the in-person workshop experience while also leveraging new opportunities afforded by virtual and online learning.

Background The categorization of pulmonary embolism (PE) as non-massive, sub-massive, and massive helps guide acute management. The presence of right ventricular (RV) strain differentiates sub-massive from non-massive PEs. Unlike laboratory markers and electrocardiogram changes, the classic parameters used in the echocardiographic diagnosis of RV strain have a technical component that is operator-dependent. Objective This narrative review will describe the physiologic effects of a PE on the RV and how this affects prognosis. It will summarize the literature evaluating the accuracy and prognostic ability of tricuspid annular plane systolic excursion (TAPSE) in the echocardiographic assessment of RVfunction. The review will describe the appeal of TAPSE for this purpose, provide cutoff measurements, and then illustrate how to perform the technique itself, while offering associated pearls and pitfalls in this bedside evaluation. Discussion RV function and dynamics undergo acute changes in the setting of a PE. RV dysfunction predicts poor outcomes in both the short and long term. However, RV strain is difficult to capture on echocardiography due to the chamber's complex geometric shape and contraction. From the apical four-chamber window, TAPSE offers a quantitative measure that is more easily performed with high interobserver reliability for evaluating systolic RV contraction. This measurement carries prognostic value in patients diagnosed with PE. Conclusions Along with other more qualitative echocardiographic parameters, TAPSE can be used as a simple quantitative measure of RV dysfunction for differentiating sub-massive from non-massive PEs. This categorization helps guide acute management and disposition.

While adult and workplace training were quick to adopt the use of online learning, many of these efforts have not advanced far beyond taking presentation slides or video recordings from formerly in-person training and making them available on learning-management systems. Compared to formal education, adult and workplace training has been much slower to iterate and improve upon early digital and virtual educational methods, leaving online learning that is viewed as neither engaging for the end-user nor effective at achieving intended outcomes. The COVID-19 pandemic and resulting lockdown added urgency to this problem, with many organizations being forced to either improve upon existing virtual training methods or finally completely replace in-person training with online options. The Ohio State University?s Center on Education and Training for Employment used evidence-based practices to develop a training collection specifically aimed at trainers, learning designers, and learning and development professionals. Translating the latest e-learning research into practical solutions, making use of proven instructional strategies, center learning designers created online training materials that are well-positioned to be effective at engaging adult learners, simultaneously instructing learners and demonstrating the learning content being delivered.

Hydrophobic membrane contactors represent a promising solution to the problem of recycling ammoniacal nitrogen (N-NH4) molecules from waste, water or wastewater resources. The process has been shown to work best with wastewater streams that present high N-NH4 concentrations, low buffering capacities and low total suspended solids. The removal of N-NH4 from rendering condensate, produced during heat treatment of waste animal tissue, was assessed in this research using a hydrophobic membrane contactor. This study investigates how the molecular composition of rendering condensate wastewater undergo changes in its chemistry in order to achieve suitability to be treated using hydrophobic membranes and form a suitable product. The main objective was to test the ammonia stripping technology using two types of hydrophobic membrane materials, polypropylene (PP) and polytetrafluoroethylene (PTFE) at pilot scale and carry out: (i) Process modification for NH3 molecule removal and (ii) product characterization from the process. The results demonstrate that PP membranes are not compatible with the condensate waste as it caused wetting. The PTFE membranes showed potential and had a longer lifetime than the PP membranes and removed up to 64% of NH3 molecules from the condensate waste. The product formed contained a 30% concentrated ammonium sulphate salt which has a potential application as a fertilizer. This is the first demonstration of hydrophobic membrane contactors for treatment of condensate wastewater.

The data are insufficient to support standardized treatment of all patients with frostbite with thrombolytic therapy. The following guidelines, however, should be applied to all patients with cyanosis persisting proximal to the distal phalanx (Grade 3 or 4 frostbite injury) and demonstrated loss of perfusion at or proximal to the middle phalanx immediately after rewarming.

A 37 year old man presented to the emergency department after being found down in a park. Initial Extended Focused Assessment with Sonography in Trauma (eFAST) was negative. On reassessment, the patient had abdominal pain and a positive eFAST. We describe the imaging modalities used to arrive at the diagnosis of intraperitoneal bladder rupture and discuss the findings that should prompt clinicians to evaluate for bladder rupture.

Objective The objective of this study is to review our experience incorporating Interactive Home Telehealth (IHT) visits into follow-up burn care. Methods A retrospective review of all burn patients participating in IHT encounters over the course of 15 months was performed. Connections were established through secure video conferencing and call-routing software. Patients connected with a personal computer or tablet and providers connected with a desktop computer with a high-definition web camera. In some cases, high-definition digital images were emailed to the provider prior to the virtual consultation. For each patient, the following was collected: (1) patient and injury demographics (diagnosis, prognosis, and clinical management), (2) total number of encounters, (3) service for each encounter (burn, psychiatry, and rehabilitation), (4) length of visit, including travel distance and time saved and, (5) complications, including re-admissions and connectivity issues. Results 52 virtual encounters were performed with 31 patients during the first year of the pilot project from March 2015 to June 2016. Mean age of the participant was 44 years (range 18–83 years). Mean total burn surface area of the participant was 12% (range 1–80%). Average roundtrip travel distance saved was 188 miles (range 4–822 miles). Average round trip travel time saved was 201 min (range 20–564 min). There were no unplanned re-admissions and no complications. Five connectivity issues were reported, none of which prevented completion of the visit. Conclusions Interactive Home Telehealth is a safe and feasible modality for delivering follow-up care to burn patients. Burn care providers benefit from the potential to improve outpatient clinic utilization. Patients benefit from improved access to multiple members of their specialized burn care team, as well as cost-reductions for patient travel expenses. Future studies are needed to ensure patient and provider satisfaction and to further validate the significance, cost-effectiveness and safety.

BACKGROUND Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures. METHODS A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected. RESULTS Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38-63) and average burn size was 35% (R 18-80). Average time from initial injury to primary reconstruction was 11.1 months (R 3-54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure. CONCLUSIONS Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.

INTRODUCTION: The COVID-19 pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume This paper describes one institution's Emergency Department innovation at the center of the COVID crisis, including the creation of a temporary ED-ICU and development of interdisciplinary COVID-specific care delivery models to care for critically ill patients METHODS: Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently resourced due to its size and lack of negative pressure (NP) rooms The ED-based Observation Unit, which has four NP rooms, was deemed to be the ideal spot for a new ED-ICU An interdisciplinary and intradepartmental task force was critical to this development This task force worked to ensure the physical supplies, medications, staffing, and clinical protocols were appropriate to allow for the proper functioning of the ED-ICU RESULTS: Within one week, the ED-based Observation Unit was quickly converted into a COVID-specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit The ED-ICU had all the functional and staffing capacities of an ICU, and was able to efficiently care for large numbers of critically ill patients All critically ill patients in the ED were treated in the ED-ICU Further, all intubations and non-invasive ventilation were able to occur in the negative pressure rooms CONCLUSIONS: The Mount Sinai Hospital Emergency Department rapidly adapted the delivery of care and treatment models to meet the challenges of the COVID-19 pandemic An ED-ICU was rapidly built by converting the prior observation area (a 27-bed zone) A redesign of a new space in a large U S academic hospital often requires months, if not years, of planning and negotiations with the varying hospital interests involved With the pressure of high COVID demand, this conversion was executed in approximately 1 week, from the initial decision to full activation Moreover, the unit functioned during the peak of the NYC COVID-19 epidemic largely as envisioned and required surprisingly few space or workflow modifications mid-course Its success was due to the hard work of the leadership team and front-line providers and the collaboration across the institution

Background Cardiac arrest in pregnancy is high acuity, low occurrence event. It involves the coordination of multiple teams to take care of ultimately two patients. This is further compounded by physiology that is frequently unfamiliar to the providers taking care of the patient. Case report This case report will detail sudden onset eclampsia in a patient whose condition deteriorated rapidly into cardiac arrest. It will delve into the complexities of managing this complex disease process and how the multi-disciplinary team quickly integrated to manage both the mother and the baby. Why should the emergency physician be aware of this?: Cardiac arrest in pregnancy is an incredibly difficult situation due to both the physiological differences in the pregnant woman and the emotional factors on the treating providers (1). Due to its rarity, the pregnant cardiac arrest situation should be frequently reviewed to ensure appropriate care when the time arrives. The per-mortem c-section for a woman in cardiac arrest is a critical resuscitation technique that must be understood by providers who take care of critically ill patients ranging from emergency medicine to obstetrics and gynecology (Ob/Gyn) clinicians.

Introduction There are an estimated 2.75 million electronic cigarette (EC) users in the United States. ECs have become the most commonly used nicotine-containing product in young adults ages 18–24 years. Thermal, blast, and missile injuries from EC explosions has grown rapidly in recent years. Burn surgeons must remain up to date regarding management and treatment of burn injuries related to EC device ignition. Methods An IRB approved retrospective review of all patients admitted to the Massachusetts General Hospital Burn Center from January 2015 to April 2017 was performed. Fourteen patients with injuries associated with EC use were identified. Patient demographics, injury location, size and degree of burn, treatments required, length of stay (LOS), time to 95% closure, associated complications and injuries, and the circumstances that led to the injury were identified. Results The mean age was 28.6 ± 8.6 years with a range of 19–50 years (n = 14). EC burns occurred in males 93% (13/14) of the time. The majority of EC explosions caused 2nd and 3rd degree burns (57%) within the same wound bed, followed by deep 2nd degree (29%), and superficial 2nd degree (14%). The average TBSA from EC burns was 4.7 ± 2.4% with a range of 1–10%. The most common location of the device or battery at the time of the injury was a pant pocket 86% (12/14), followed by 7% hand (1/14) and 7% purse (1/14). Isolated lower extremity burns occurred in 43% (6/14) of patients, while lower extremity and hand burns occurred in 21% (3/14) of patients. Nine of 14 patients required an operating room encounter under general anesthesia. Eight of 14 patients required skin grafting for definitive wound closure. The mean hospital length of stay was 6.6 ± 4.7 days with a range of 0–15 days. Time to 95% wound closure was 18.4 ± 10.8 with a range of 8–40 days. Conclusion Thermal and blast injuries associated with EC device failure tend to cause small TBSA burns that are deep 2nd and 3rd degree wounds. The most common location for EC device storage among males was the front pants pocket. EC device users should be made aware of the dangers associated with EC use and advised to carry EC devices away from their body in dedicated carrying cases without loose metallic items.

Amniotic membrane is immunologically privileged and is a reservoir of growth factors and cytokines known to modulate inflammation and enhance the healing process, while also possessing antimicrobial, antifibrosis, and antiscarring properties. These properties establish a strong argument for using amniotic membrane derived products as a treatment for burns. The purpose of this article is to describe the use of commercially available dehydrated human amnion/chorion membrane allografts in patients with partial-thickness and full-thickness burns.

Purpose/objectives To create and evaluate an educational video designed to increase breast cancer-related knowledge and screening behaviors among women who are deaf and use American Sign Language (ASL) as their preferred communication method. Design A test-retest survey was used to determine retained knowledge following an intervention with an ASL breast cancer education video. Setting Deaf-friendly community settings in southern California. Sample 122 women who were deaf with a preference for communicating via ASL. Methods Participants completed a knowledge survey to determine their breast cancer screening practices and baseline breast cancer awareness. Participants then viewed a 30-minute video in ASL. Immediately after viewing the video, participants completed an identical knowledge survey. The survey was administered again two months after the initial intervention to determine long-term breast cancer knowledge retention. Main research variables Age, breast cancer knowledge and screening practices, education, and health insurance. Findings At baseline, breast cancer knowledge varied widely and respondents' answered an average of 3 out of 10 questions correctly. Postintervention, respondents answered an average of 8 out of 10 questions correctly, a significant increase from the baseline scores. At the two-month follow-up, respondents answered an average of 6 out of 10 questions correctly, still a significant increase from the baseline scores. Conclusions Breast cancer knowledge of women who are deaf increased significantly by viewing an educational video in ASL and most of the new knowledge remained at the two-month follow-up. Implications for nursing Nurses can help improve the Deaf community's (DC's) access to breast cancer-related information by disseminating awareness of this online program. Knowledge translation With this online resource, nurses can more easily initiate discussions to help improve knowledge and screening behaviors in a linguistically and culturally appropriate manner. Improving the DC's access to breast cancer information is of paramount importance to reducing breast cancer morbidity and mortality in the DC.

UnlabelledAn ideal substance to provide convenient and accurate targeting for sentinel lymph node (SLN) mapping during robotic-assisted surgery has yet to be found. We used an animal model to determine the ability of the FireFly camera system to detect fluorescent SLNs after administration of a dual-labeled molecular imaging agent.MethodsWe injected the footpads of New Zealand White rabbits with 1.7 or 8.4 nmol of tilmanocept labeled with (99m)Tc and a near-infrared fluorophore, IRDye800CW. One and 36 h after injection, popliteal lymph nodes, representing the SLNs, were dissected with the assistance of the FireFly camera system, a fluorescence-capable endoscopic imaging system. After excision of the paraaortic lymph nodes, which represented non-SLNs, we assayed all lymph nodes for radioactivity and fluorescence intensity.ResultsFluorescence within all popliteal lymph nodes was easily detected by the FireFly camera system. Fluorescence within the lymph channel could be imaged during the 1-h studies. When compared with the paraaortic lymph nodes, the popliteal lymph nodes retain greater than 95% of the radioactivity at both 1 and 36 h after injection. At both doses (1.7 and 8.4 nmol), the popliteal nodes had higher (P < 0.050) optical fluorescence intensity than the paraaortic nodes at the 1- and 36-h time points.ConclusionThe FireFly camera system can easily detect tilmanocept labeled with a near-infrared fluorophore at least 36 h after administration. This ability will permit image acquisition and subsequent verification of fluorescence-labeled SLNs during robotic-assisted surgery.