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Introduction: Standard emergency medicine practice includes tetanus vaccine administration as part of wound care management for patients who are not fully immunized. Since there have been no available studies in the United States reaffirming the prevalence of Clostridium tetani (C tetani) since 1926, we sought to identify its prevalence in a major urban county in the US.Methods: We sampled soil, rusted metal, concrete, and dog feces to determine the prevalence of C tetani in a single metropolitan county in the United States. Soil samples and swabs were collected from four locations: the soil of a public park and an elementary school; dog feces from a single public dog park; and rusted surfaces (metal and concrete) in common student areas of a university campus. The presence of C tetani in each sample was determined using a quantitative polymerase chain reaction.Results: In total, 200 samples were collected, of which 37 (18.5%) tested positive for C tetani DNA. Among the 140 samples taken from the soil, just one (0.7%) tested positive for C tetani DNA. Of the 40 samples of rusted metal and concrete surfaces, 30 (75%) tested positive for C tetani, and six (30%) of the 20 samples from dog feces tested positive for C tetani.Conclusion: We found that C tetani is frequently present on rusted metal and concrete surfaces but rarely in soil samples. Minor wounds contaminated with soil may be considered low risk for tetanus. However, future studies should assess the burden of C tetani in other similar urban, suburban, and rural environments to help determine the threat of C tetani more exactly.

Background: Increasingly, patient satisfaction scores are being used to assess emergency physicians. We sought to determine whether the patient satisfaction scores collected by our hospital system are lower for patients who are treated in the emergency department (ED) on night shifts as compared to those treated on day shifts.Methods: We performed a cross-sectional analysis of patient satisfaction scores from three EDs in Florida. We obtained satisfaction data from NRC Health (the company that provides our surveys) using a random sample of 1,000 completed surveys from patients treated in 2022; we also performed manual chart review to obtain clinical data. The satisfaction surveys asked patients how likely they would be to recommend the facility (from 0–10). Patients who provided a score of 9 or 10 were considered “promoters.” For our primary analysis, we compared the percentage of promoters for the day shift encounters (7 AM to 7 PM) to the night shift encounters (7 PM to 7 AM). We also performed a multivariable logistic regression analysis using several demographic and clinical variables to further assess the association between night shift arrival and satisfaction scores.Results: Of the 1,000 surveys analyzed, 66.3% of patients arrived during the day shift, and 33.7%arrived during the night shift. Of those who arrived during the day shift, 525 (79.2%) were promoters compared to 228 (67.7%) of those who arrived during the night shift, a difference of 11.5% (95%confidence interval [CI] 5.7–17.4%), P < 0.001. On multivariable analysis, night shift arrival was associated with a lower chance of a patient being a promoter, with adjusted odds ratio 0.60 (95% CI 0.43–0.84), P = 0.003.Conclusion: Patients who presented to the ED during the night shift were less likely to be promoters than patients who arrived during the day shift. Assessments of patient satisfaction data should account for time of visit and other facility-related and operational characteristics.

Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a “negative” rapid COVID-19 test that their test result was “indeterminate.”

Many public officials are calling for increased testing for the 2019 novel coronavirus disease (COVID-19), and some governments have taken extraordinary measures to increase the availability of testing. However, little has been published about the sensitivity and specificity of the reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs that are commonly used for testing. This narrative review evaluates the literature regarding the accuracy of these tests, and makes recommendations based on this literature. In brief, a negative RT-PCR nasopharyngeal swab test is insufficient to rule out COVID-19. Thus, over-reliance on the results of the test may be dangerous, and the push for widespread testing may be overstated.

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

Introduction: Computed tomography pulmonary angiography (CTPA) is the test of choice for diagnosis of pulmonary embolism (PE) in the emergency department (ED), but this test may be indeterminate for technical reasons such as inadequate contrast filling of the pulmonary arteries.  Many hospitals have requirements for intravenous (IV) catheter size or location for CTPAs to reduce the chances of inadequate filling, but there is a lack of clinical data to support these requirements. The objective of this study was to determine if a certain size or location of IV catheter used for contrast for CTPA is associated with an increased chance of an indeterminate CTPA. Methods: This was a retrospective chart review of patients who underwent CTPA in the emergency department.  A CTPA was considered indeterminate if the radiology report indicated it was inadequate to exclude a pulmonary embolism.  The reason for the study being indeterminate, and the size and location of the IV catheter were abstracted. The rate of inadequate contrast filling of the pulmonary vasculature was calculated and compared for various IV catheter sizes and locations.  In particular, 20-gauge or larger IV catheters in the antecubital fossa or forearm were compared to all other sizes and locations. Results: A total of 19.3% of the 1500 CTPA reports reviewed met our criteria as indeterminate, and 51.6% of those were due to inadequate filling.  Patients with a 20-gauge IV catheter or larger placed in the antecubital fossa or forearm had inadequate filling 9.2% of the time compared to 13.2% for patients who had smaller IVs or IVs in other locations (difference:  4.0% [95% CI -1.7% to 9.7%]).  There were also no statistically significant differences in the rates of inadequate filling when data were further stratified by IV catheter location and size. Conclusion: We did not detect any statistically significant differences in the rate of inadequate contrast filling based on IV catheter locations or sizes.  While small differences not detected in this study may exist, it seems prudent to proceed with CTPA in patients with difficult IV access who need emergent imaging even if they have a small or distally located IV.

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications.Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections.  Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access.

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique have not been fully elucidated. The objective of this study is to determine the accuracy of emergency medicine resident-performed two-point compression ultrasound, and to determine what technical errors are commonly made by novice ultrasonographers using this technique.Methods: This was a prospective diagnostic test assessment of a convenience sample of adult emergency department (ED) patients suspected of having a lower extremity DVT. After brief training on the technique, residents performed two-point compression ultrasounds on enrolled patients. Subsequently a radiology department ultrasound was performed and used as the gold standard. Residents were instructed to save videos of their ultrasounds for technical analysis.Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28 cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were identified by the residents with two-point compression. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95% CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a positive predictive value of 61.5% (95% CI 42.8% to 80.2%) and a negative predictive value of 95.4% (95% CI 92.9% to 98.0%).  The positive likelihood ratio is 14.9 (95% CI 7.5 to 29.5) and the negative likelihood ratio is 0.45 (95% CI 0.29 to 0.68). Video analysis revealed that in four cases the resident did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which is not evaluated by two-point compression. Moreover, the video analysis revealed that the most common mistake made by the residents was inadequate visualization of the popliteal vein.Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in part because novice ultrasonographers have difficulty properly assessing the popliteal vein.

Introduction: In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. Objective: A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. Methods: This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. Findings: From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion. Conclusion: Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced. [ABSTRACT FROM AUTHOR]

Objectives: Patients frequently present to the emergency department (ED) with neck or back pain, which can be difficult to treat. We sought to compare ultrasound‐guided trigger point injection (TPI) to standard medications for patients with neck or back pain. Methods: We performed a single‐center, open label, randomized controlled trial on ED patients with neck or back pain from myofascial pain syndrome comparing ultrasound‐guided TPIs to those who received the combination of a nonsteroidal anti‐inflammatory drug (NSAID) and a muscle relaxant (MR). The primary outcome of this study was the reduction in mean pain score at the time of ED disposition. Results: In total, we analyzed 196 patients. At the time of ED disposition, patients in the TPI group had a mean reduction in their pain scores of 45.0 mm as compared to 49.9 mm in the NSAID plus MR group (difference: 4.9 [95% confidence interval (CI) −3.0 to 12.7], P =.22). At the first reassessment, patients in the TPI group had greater pain reduction by 10.7 mm (95% CI 3.1 to 18.4). The rate of rescue therapy use was higher in the NSAID plus MR group (difference: 17.5% [95% CI 4.4 to 36.2]). Conclusions: We found no difference in pain reduction at the time of ED disposition between patients randomized to the ultrasound‐guided TPI group as compared to those who received an NSAID plus a MR. However, patients in the TPI group had greater pain reduction at the time of first reassessment and lower rates of rescue therapy use. [ABSTRACT FROM AUTHOR]