A standardized protocol using clinical adjudication to define true infection status in patients presenting to the emergency department with suspected infections and/or sepsis.

In absence of a "gold standard", a standardized clinical adjudication process was developed for a registrational trial of a transcriptomic host response (HR) test. Two physicians independently reviewed clinical data to adjudicate presence and source of bacterial and viral infections in emergency department patients. Discordant cases were resolved by a third physician. Agreement among 955 cases was 74.1% (708/955) for bacterial, 75.6% (722/955) for viral infections, and 71.2% (680/955) overall. Most discordances were minor (85.2%; 409/480) versus moderate (11.7%; 56/480) or complete (3.3%; 16/480). Concordance levels were lowest for bacterial skin and soft tissue infections (8.2%) and for viral respiratory tract infections (4.5%). This robust adjudication process can be used to evaluate HR tests and other diagnostics by regulatory agencies and for educating clinicians, laboratorians, and clinical researchers. Clinicaltrials.gov NCT04094818. SUMMARY: Without a gold standard for evaluating host response tests, clinical adjudication is a robust reference standard that is essential to determine the true infection status in diagnostic registrational clinical studies.

Nebulized medications in the emergency department: A narrative review of nontraditional agents.

PURPOSE: This article summarizes emerging nontraditional therapies administered via the nebulization route for use in the emergency department (ED). SUMMARY: Although traditional routes of medication administration (eg, intravenous) have been the mainstay of administration modalities for decades, these routes may not be appropriate for all patients. Nowhere is this more readily apparent than in the ED setting, where patients with a variety of presentations receive care. One unique route for medication administration that has increasingly gained popularity in the ED is that of aerosolized drug delivery. This route holds promise as direct delivery of medications to the site of action could yield a more rapid and effective therapeutic response while also minimizing systemic adverse effects by utilizing a fraction of the systemic dose. Medication administration via nebulization also provides an alternative that is conducive to rapid, less invasive access, which is advantageous in the emergent setting of the ED. This review is intended to analyze the existing literature regarding this route of administration, including the nuances that can impact drug efficacy, as well as the available literature regarding novel, noncommercial nebulized medication therapy given in the ED. CONCLUSION: Multiple medications have been investigated for administration via this route, and when implementing any of these therapies several practical considerations must be taken into account, from medication preparation to administration, to ensure optimal efficacy while minimizing adverse effects. The pharmacist is an essential bedside team member in these scenarios to assist with navigating unique and complex nuances of this therapy as they develop.

Prevalence of Hepatitis C Virus Infection Identified From Nontargeted Screening Among Adult Visitors in an Academic Appalachian Regional Emergency Department.

BACKGROUND: We describe the initial results of an adult academic emergency department (ED) nontargeted hepatitis C virus (HCV) screening program serving Appalachia, which is disproportionately affected by the opioid epidemic. METHODS: The study was a retrospective screening study of ED systematic, nontargeted, opt-out HCV testing outcomes from July 2018 through September 2020. Eligibility requirements for "nontargeted" HCV testing included age ≥18 years, verbally able to communicate, receiving bloodwork already as part of routine clinical care, and not opting out of testing. For eligible individuals who did not opt out of testing, an HCV antibody (Ab) test was performed. Reactive Ab tests were confirmed with reflexive HCV RNA testing. The primary study outcome was the characterization of HCV Ab and RNA prevalence. RESULTS: There were 75 722 unique adult visitors during the period studied. Of these, 54 931 individuals were verbally engaged regarding testing and did not opt out. A total of 34 848 individuals received HCV Ab testing, with 3665 patients (10.5%) having reactive results. RNA confirmatory testing was reflexively performed in all Ab-positive patients, with 1601 (50.3%) positive. The majority of HCV Ab- and RNA-positive patients were young, born after 1965, and were more likely to be White, male, Medicaid insured, and report a history of injection drug use. CONCLUSIONS: ED nontargeted, opt-out testing can identify a high prevalence of HCV infection among adult visitors. HCV infection was disproportionately high among younger, White individuals, likely reflecting the escalating syndemic of opioid injection and HCV transmission in Appalachia.

Pain Medication Administered and Prescribed to Patients With an Ankle Sprain Treated in an Emergency Department: A Record-Based Cohort Study.

INTRODUCTION: Recent data indicate that patients treated in the emergency department for an ankle sprain receive multiple medications. However, research has not been able to accurately identify all the medications because of study limitations. The primary purpose of this study was to document the type of medication, number of doses, and number of encounters given a prescription at discharge or instructions to take over-the-counter medication. The secondary purpose was to determine if the proportion of encounters given each type of medication varied on the basis of age, sex, race, and year. METHODS: A retrospective record-based cohort study design was used to review the electronic medical records (N = 1740) of encounters reporting to a southeast academic level 1 trauma center and diagnosed with an ankle sprain between 2013 and 2017. All relevant data were extracted for nonsteroidal anti-inflammatory drugs, muscle relaxants, opioids, and nonopioid analgesics. RESULTS: Fifty-eight percent of the encounters had at least 1 dose of medication administered in the emergency department. Twenty-eight percent received a prescription at discharge, and 54.5% were instructed to take over-the-counter medication. Cumulatively, opioids accounted for most of the medications, but the yearly rates declined from 2013 to 2017. A greater proportion of patients aged ≤15 years received nonsteroidal anti-inflammatory drugs or nonopioid analgesics. Most of the patients aged >15 years received opioid medication. DISCUSSION: Patients are primarily given an opioid or nonsteroidal anti-inflammatory drug in the emergency department. Fewer patients receive a prescription at discharge but are regularly instructed to take over-the-counter medication.

Medications Used in U.S. Emergency Departments for an Ankle Sprain: An Analysis of the National Hospital Ambulatory Medical Care Survey.

BACKGROUND: An ankle sprain is a common musculoskeletal injury treated in the emergency department. Rest, ice, compression, and elevation is the preferred method for managing the symptoms after an ankle sprain. However, many patients receive a medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or an opioid. OBJECTIVES: We sought to quantify the type of medication(s) used for an ankle sprain and to examine those across age and sex. METHODS: This was a retrospective review of the publicly available data collected through the National Hospital Ambulatory Medical Care Survey from 2006-2015. All cases with an isolated diagnosis of an ankle sprain were identified. Medication listed for each case was classified based on its detailed category and further explored across all 10 years, age, and sex. RESULTS: An estimated 9,052,678 ankle sprain visits occurred in emergency departments from 2006-2015. NSAIDs (56.1%) and opioid analgesic combination (28.4%) were the 2 most common medications. Regardless of the type, most medications were prescribed at discharge. The use of NSAIDs appears to have increased while opioid analgesic combinations decreased in 2010. NSAIDs were the most common medication identified with each age cohort; however, there was no apparent trend in medication for sex. CONCLUSIONS: NSAIDs are the most common medication used for ankle sprain visits to the ED. Nevertheless, an opioid is also used at a relatively high rate for this injury. These findings provide awareness and opportunity to focus on strategies for reduction of opioid use.

High-Dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review.

BACKGROUND: Symptomatic tachycardia is a common admission diagnosis in the emergency department (ED). This can be a life-threatening condition and requires immediate attention. Supraventricular tachycardia (SVT) is commonly treated with adenosine, and successful treatment is limited to atrioventricular (AV) node-dependent SVTs as adenosine causes a transient heart block. However, there are limited data available for instances when the recommended dosing regimen (6 mg, 12 mg, 12 mg) fails to terminate SVT. CASE REPORT: A 33-year old man was evaluated in the ED with an electrocardiogram revealing a regular narrow complex tachycardia with a heart rate of 180 beats/min and a rhythm consistent with SVT. He reported experiencing 3 days of fatigue, myalgias, palpitations, and dyspnea on exertion, but was otherwise hemodynamically stable. Attempts at chemical cardioversion with standard doses of adenosine (6 mg, 12 mg, and 12 mg) were given without success. After consultation with the cardiology service, additional doses of 24 mg and then 36 mg of adenosine were administered. The last dose of 36 mg produced sustained conversion and return to a normal sinus rhythm. The patient later underwent radiofrequency ablation of a left-sided orthodromic reciprocating accessory pathway. After 3 months of medical management, the patient had an implantable cardiac defibrillator placed for prevention of sudden cardiac death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Each case of SVT demands immediate attention from an emergency physician. It is imperative that providers be aware of the limitations of adenosine and when it may be appropriate to deviate from standard dosing recommendations. This is in addition to collaborating with an expert in cardiac electrophysiology when initial management tactics are not successful.

Analytical and Clinical Evaluation of the NOWDiagnostics ADEXUSDx Human Chorionic Gonadotropin Test Using Whole Blood.

BACKGROUND: Point-of-care (POC) urine qualitative human chorionic gonadotropin (hCG) devices are used to rapidly assess pregnancy status, but many of these devices are susceptible to false-negative results caused by increased concentrations of hCG ß core fragment (hCGßcf) that does not contain hCGßcf. METHODS: Purified hCG was added to hCG-negative heparinized whole blood to generate samples with known hCG concentrations, and the resulting samples were used to evaluate device sensitivity, low-end reproducibility, high-dose hook effect, intermediate range performance, acceptable sample volume, acceptable hematocrit range, and lot-to-lot variation. Device performance was also prospectively evaluated in 40 pregnant and 40 nonpregnant women aged 18-44 years in a hospital-based clinic or an academic hospital emergency department. RESULTS: All device observations were positive using a whole blood sample containing a plasma hCG concentration of 2.2 × 106 IU/L, and all device observations were positive from18 IU/L to 1.2 × 103 IU/L and from 2.5 × 104 IU/L to 2.2 × 106 IU/L. Three invalid results were observed in the intermediate range because of decreased control line intensity. The minimum sample volume was 30 µL, and maximum hematocrit was 46%. In 40 pregnant and 40 nonpregnant women aged 18-44 years, the device generated 100% concordance with urine qualitative and plasma quantitative test results. CONCLUSIONS: The ADEXUSDx™ hCG test demonstrates acceptable performance for the determination of pregnancy status using capillary fingerstick samples.

Colloid cyst: a case report and literature review of a rare but deadly condition.

BACKGROUND: Colloid cysts are congenital benign tumors accounting for 0.2-2% of all intracranial neoplasms but representing 15-20% of all intraventricular masses. Emergency Physicians are more likely than any other group to encounter patients with a colloid cyst, a rare but life-threatening condition. The most common presenting complaint is severe episodic attacks of headache in a frontal location with associated nausea and vomiting. OBJECTIVES: To describe a rare but potentially life-threatening cause of headache so that clinicians will rapidly recognize the significance of the condition and institute timely appropriate therapy. CASE REPORT: We describe the case of a 40-year-old man with a severe headache accompanied by confusion who was diagnosed with obstructive hydrocephalus associated with a colloid cyst in the third ventricle. CONCLUSION: Recognition of this rare but important diagnosis should prompt the Emergency Physician to obtain timely treatment so that rapid neurologic deterioration, herniation, and death can be prevented. A review of the pathophysiology, diagnosis, and current management is discussed.

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department.

PURPOSE: The effect of an emergency medicine (EM) clinical pharmacist on medication-error reporting in an emergency department (ED) was studied. METHODS: The medication-error reports for patients seen at a university's ED between September 1, 2005, and February 28, 2009, were retrospectively reviewed. Errors reported before the addition of an EM pharmacist (from September 1, 2005, through February 28, 2006) were compared with those reported after the addition of two EM pharmacists (from September 1, 2008, through February 28, 2009). The severity of errors and the provider who reported the errors were characterized. RESULTS: A total of 402 medication errors were reported over the two time periods. Pharmacy personnel captured significantly more errors than did other health care personnel (94.5% versus 5.7%, p < 0.001). The addition of two EM pharmacists resulted in 14.8 times as many medication-error reports as were made when no EM pharmacist was in the ED. More errors that actually occurred were captured with two pharmacists providing care (95.7% versus 4.3%, p < 0.001). A majority of the errors documented were ordering errors (79.8%). Of these, 73.7% were captured after the addition of two EM pharmacists. Performance (40.0%) and knowledge (27.9%) deficits were the most common contributing factors to medication errors. CONCLUSION: During the study period after the addition of two EM pharmacists in the ED, 371 medication-error reports were completed, compared with 31 reports during the study period before the addition of the pharmacists. Pharmacy personnel reported the majority of medication errors during both study periods.

Pharmacologic options for reducing the shivering response to therapeutic hypothermia.

Recent literature has demonstrated significant improvements in neurologic outcomes in patients who have received induced hypothermia in the setting of out-of-hospital cardiac arrest. Through multiple metabolic mechanisms, the induction of hypothermia slows the progression and devastation of transient cerebral hypoxia. Despite these benefits, the desired reduction in core temperature is often a challenging venture as the body attempts to maintain homeostasis through the induction of thermoregulatory processes aimed at elevating body temperature. Shivering is an involuntary muscular activity that enhances heat production in an attempt to restore homeostasis. For successful induction and maintenance of induced hypothermia, shivering, as well as other thermoregulatory responses, must be overcome. Several pharmacologic options are available, either used alone or in combination, that safely and effectively prevent or treat shivering after the induction of hypothermia. We conducted a PubMed search (1966-March 2009) to identify all human investigations published in English that discussed pharmacologic mechanisms for the control of shivering. Among these options, clonidine, dexmedetomidine, and meperidine have demonstrated the greatest and most clinically relevant impact on depression of the shivering threshold. More research in this area is needed, however, and the role of the clinical pharmacist in the development and implementation of this therapy needs to be defined.

Current developments in salivary diagnostics.

Salivary diagnostics is an emerging field that has progressed through several important developments in the past decade, including the publication of the human salivary proteome and the infusion of federal funds to integrate nanotechnologies and microfluidic engineering concepts into developing compact point-of-care devices for rapid analysis of this secretion. In this article, we discuss some of these developments and their relevance to the prognosis, diagnosis and management of periodontitis, as an oral target, and cardiovascular disease, as a systemic example for the potential of these biodiagnostics. Our findings suggest that several biomarkers are associated with distinct biological stages of these diseases and demonstrate promise as practical biomarkers in identifying and managing periodontal disease, and acute myocardial infarction. The majority of these studies have progressed through biomarker discovery, with the identified molecules requiring more robust clinical studies to enable substantive validation for disease diagnosis. It is predicted that with continued advances in this field the use of a combination of biomarkers in multiplex panels is likely to yield accurate screening tools for these diagnoses in the near future.

Role of cardiac computed tomography and magnetic resonance imaging in the evaluation of acute chest pain in the emergency department.

Evaluation of patients presenting with chest pain to the emergency department remains a challenging task because of a variety of etiologies that range from benign to potentially fatal. Although majority of patients do not have myocardial ischemia as the cause of their presentation, the clinical work up can be time consuming, costly and inconclusive. Recent technical advances in cardiac computed tomography and magnetic resonance imaging have led to better diagnostic accuracy in evaluating patients with chest pain. In this paper, we review the role of cardiac computed tomography and magnetic resonance imaging in evaluating patients with chest pain in the emergency department.

An assessment of pediatric all-terrain vehicle injuries.

OBJECTIVES: All-terrain vehicle (ATV) related injuries and deaths have been increasing since 1996. The objective of this study is to define the impact on the morbidity and mortality of the pediatric population of the referral area of one of Kentucky's level-1 trauma centers. METHODS: Data were collected retrospectively from the University of Kentucky Trauma Registry on all patients younger than 18 years of age admitted to the level 1 trauma center between 1996 and 2000 with ATV related injuries. RESULTS: One hundred fifty-one pediatric patients were hospitalized from an ATV-related injury during the study period. There were five deaths. The male/female ratio was 3.2:1. The mean revised trauma score was 7.3 +/- 1.3. The mean injury severity score was 12.3 +/- 8.9. Helmet use was only 4%. The average hospitalization was 4.4 +/- 5.2 days, 32% went to the intensive care unit and 52% to the operating room. Forty percent of patients had multisystem injuries. Passengers were younger than drivers (9.3 +/- 4.9 and 13.3 +/- 2.7 years, respectively). Hospital charges exceeded dollar 2.1 million. CONCLUSION: All-terrain vehicle-related injuries led to significant morbidity and mortality for the pediatric population of southern and southeastern Kentucky. Encouraging helmet use and discouraging passengers from riding through safety education or a new state law may help to reduce ATV related mortality and morbidity. Prohibiting children younger than 16 years from operating or riding on an ATV seems justified.