Targeted Temperature Management Using Esophageal Cooling.

Although specific temperature targets are debated, targeted temperature management (TTM) is a common treatment for postcardiac arrest patients. However, consistently implementing a TTM protocol is challenging, especially in a community hospital. Often, the protocols described in the literature include labor- and cost-intensive methods that are not feasible or sustainable in many health care settings. Esophageal temperature management (ETM) is a TTM method that can be easily utilized alone or combined with surface methods. We sought to evaluate ETM in a cohort of patients treated with TTM after cardiac arrest. Chart reviews were conducted of all patients treated with ETM after cardiac arrest at our community medical center. Initial patient temperature, time to target, supplemental methods (water blankets, chest wraps, or head wraps), and patient survival were extracted for analysis. A total of 54 patients were treated from August 2016 to November 2018; 30 received ETM only, 22 received supplemental cooling, and 2 had treatment discontinued before reaching target due to recovery. Target temperatures ranged from 32°C to 36°C, depending on provider preference. The median time to target temperature for the entire cohort was 219 minutes (interquartile range [IQR] 81-415). For the cohorts without, and with, supplemental cooling modalities, the median time to attain target temperature was 128 minutes (IQR 71-334), and 285 minutes (IQR 204-660), respectively. Survival to intensive care unit discharge was 51.9% for the entire cohort. Survivors exhibited longer times to achieve goal temperature (median 180 minutes in nonsurvivors vs. 255 minutes in survivors). ETM attains target temperature at a rate consistent with current guidelines and with similar performance to alternative modalities. As in other studies, surviving patients required longer times to reach target temperature.

Respiratory Distress in the Pediatric ED: A Case-based Self-directed Learning Module.

Audience: Emergency medicine residents, pediatric residents on an EM rotation. Introduction: Emergency medicine residents are expected to recognize and treat patients of all ages and diseases of all varieties, yet most education and training is focused on the adult patient. Exposure to pediatrics is generally integrated into training across all years of residency, but time spent in the pediatric emergency department is still a small portion of resident education. This module aims to enhance the ability of the emergency medicine residents to recognize and treat respiratory distress in children, one of the most common presenting chief complaints in the pediatric population, by integrating the concepts of case-based learning, self-directed learning and self-testing. Educational Objectives: By the end of this module, learners will be able to: 1) recognize the unique pathophysiology for respiratory distress in the pediatric population and formulate a broad differential; 2) understand the treatment principles for the most common causes of respiratory distress in children; 3) navigate and apply validated clinical decision-making tools for treatment of pediatric respiratory illnesses. Educational Methods: A learning module consisting of six clinical vignettes based on the most common causes of respiratory distress in children, with associated self-test questions, and key learning concepts was created for resident education. This module was a self-directed PowerPoint slideshow with embedded questions and links to evidence-based clinical decision-making tools. Research Methods: A survey was created to gauge the residents' perceptions of the learning module and its usefulness in their learning. Results: Twenty (30%) residents used this module and took the survey. Ninety percent of respondents felt more comfortable managing respiratory distress in children after completing this module. Ninety-five percent of respondents felt they had sufficient knowledge of the topic after completing the module and would like to have more modules such as this one on other topics. Discussion: Residents indicated in the survey that the module enhanced their knowledge and comfort with clinical practice. This unique learning module integrates basic and clinical sciences and utilizes many different learning concepts to engage and motivate the adult learner. The module may also be re-created in order to cover other similar topics as a supplement to resident education. Topics: Pediatrics, respiratory, infectious disease, asthma, croup, anaphylaxis, foreign body aspiration, bronchiolitis, laryngomalacia.

Can Medical Students Learn and Perform POCUS in the Pediatric Emergency Department? Implementation of a Short Curriculum.

Purpose: To determine medical student ability to accurately obtain and interpret POCUS exams of varying difficulty in the pediatric population after a short didactic and hands-on POCUS course. Methods: Five medical students were trained in four POCUS applications (bladder volume, long bone for fracture, limited cardiac for left ventricular function, & inferior vena cava collapsibility) and enrolled pediatric ED patients. Ultrasound-fellowship-trained emergency medicine physicians reviewed each scan for image quality and interpretation accuracy using the American College of Emergency Physicians' quality assessment scale. We report acceptable scan frequency and medical student vs. Ultrasound-fellowship-trained emergency medicine physician interpretation agreement with 95% confidence intervals (CI). Results: Ultrasound-fellowship-trained emergency medicine physicians graded 51/53 bladder volume scans as acceptable (96.2%; 95% CI 87.3-99.0%) and agreed with 50/53 bladder volume calculations (94.3%; 95% CI 88.1-100%). Ultrasound-fellowship-trained emergency medicine physicians graded 35/37 long bone scans as acceptable (94.6%; 95% CI 82.3-98.5%) and agreed with 32/37 medical student long bone scan interpretations (86.5%; 95% CI 72.0-94.1%). Ultrasound-fellowship-trained emergency medicine physicians graded 116/120 cardiac scans as acceptable (96.7%; 95% CI 91.7-98.7%) and agreed with 111/120 medical student left ventricular function interpretations (92.5%; 95% CI 86.4-96.0%). Ultrasound-fellowship-trained emergency medicine physicians graded 99/117 inferior vena cava scans as acceptable (84.6%; 95% CI 77.0-90.0%) and agreed with 101/117 medical student interpretations of inferior vena cava collapsibility (86.3%; 95% CI 78.9-91.4%). Conclusions: Medical students demonstrated satisfactory ability within a short period of time in a range of POCUS scans on pediatric patients after a novel curriculum. This supports the incorporation of a formal POCUS education into medical school curricula and suggests that novice POCUS learners can attain a measure of competency in multiple applications after a short training course.

A survey of handoff practices in emergency medicine.

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.

An algorithm for transition of care in the emergency department.

OBJECTIVES: The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). METHODS: This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. RESULTS: The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of "high-risk" handoffs, and the opportunity for questions and clarification from the handoff recipient. The developed handoff algorithm consisted of five steps: 1) setting the stage, 2) assembling the team, 3) identification of high-risk patients, 4) shift sign-out, and 5) closing the loop. CONCLUSIONS: The authors present specific guidelines for an algorithm-based approach to transitioning care within the ED. This algorithm is based on surveys of perceived deficiencies and emphasizes informational and logistical parameters within a ToC. Standardizing the process of the ToC may allow for future research on the link between effective ToC and patient outcomes.

Assessing patient care: summary of the breakout group on assessment of observable learner performance.

There is an established expectation that physicians in training demonstrate competence in all aspects of clinical care prior to entering professional practice. Multiple methods have been used to assess competence in patient care, including direct observation, simulation-based assessments, objective structured clinical examinations (OSCEs), global faculty evaluations, 360-degree evaluations, portfolios, self-reflection, clinical performance metrics, and procedure logs. A thorough assessment of competence in patient care requires a mixture of methods, taking into account each method's costs, benefits, and current level of evidence. At the 2012 Academic Emergency Medicine (AEM) consensus conference on educational research, one breakout group reviewed and discussed the evidence supporting various methods of assessing patient care and defined a research agenda for the continued development of specific assessment methods based on current best practices. In this article, the authors review each method's supporting reliability and validity evidence and make specific recommendations for future educational research.

The implementation of therapeutic hypothermia in the emergency department: a multi-institution case review.

BACKGROUND: The use of therapeutic hypothermia (TH) is a burgeoning treatment modality for post-cardiac arrest patients. OBJECTIVES: We performed a retrospective chart review of patients who underwent post-cardiac arrest TH at eight different institutions across the United States. Our objectives were to assess how TH is currently being implemented in emergency departments and to examine the feasibility of conducting TH research using multi-institution prospective data. METHODS: A total of 94 cases were identified in a 3-year period and submitted for review by participating institutions of the Peri-Resuscitation Consortium. Of those, seven charts were excluded for missing data. Two independent reviewers performed the data abstraction. Results were subsequently compared, and discrepancies were resolved by a third reviewer. We assessed patient demographics, initial presenting rhythm, time until TH initiation, duration of TH, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharged. RESULTS: The majority of cases had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%). The inciting cardiac rhythm was unknown in 10.3% of cases. Time to initiation of TH ranged from 0 to 783 minutes with a mean time of 99 minutes (SD=132). Length of TH ranged from 25 to 2,171 minutes with a mean time of 1,191 minutes (SD=536). The average minimum temperature achieved was 32.5°C, with a range from 27.6°C to 36.7°C (SD=1.5°C). Of the 87 charts reviewed, 29 (33.3%) of the patients survived to hospital discharge. CONCLUSION: The implementation of TH across the country is extremely varied with no universally accepted treatment. While our study is limited by sample size, it illustrates some compelling trends. A large, prospective, multicenter trial or registry is necessary to elucidate further the optimal parameters for TH and its benefit in various population subsets.

Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock.

BACKGROUND: New scoring systems, including the Rapid Emergency Medicine Score (REMS), the Mortality in Emergency Department Sepsis (MEDS) score, and the confusion, urea nitrogen, respiratory rate, blood pressure, 65 years and older (CURB-65) score, have been developed for emergency department (ED) use in various patient populations. Increasing use of early goal directed therapy (EGDT) for the emergent treatment of sepsis introduces a growing population of patients in which the accuracy of these scoring systems has not been widely examined. OBJECTIVES: To evaluate the ability of the REMS, MEDS score, and CURB-65 score to predict mortality in septic patients treated with modified EGDT. MATERIALS AND METHODS: Secondary analysis of data from prospectively identified patients treated with modified EGDT in a large tertiary care suburban community hospital with over 85,000 ED visits annually and 700 inpatient beds, from May 2007 through May 2008. We included all patients with severe sepsis or septic shock, who were treated with our modified EGDT protocol. Our major outcome was in-hospital mortality. The performance of the scores was compared by area under the ROC curves (AUCs). RESULTS: A total of 216 patients with severe sepsis or septic shock were treated with modified EGDT during the study period. Overall mortality was 32.9%. Calculated AUCs were 0.74 [95% confidence interval (CI): 0.67-0.81] for the MEDS score, 0.62 (95% CI: 0.54-0.69) for the REMS, and 0.59 (95% CI: 0.51-0.67) for the CURB-65 score. CONCLUSION: We found that all three ED-based systems for scoring severity of illness had low to moderate predictive capability. The MEDS score demonstrated the largest AUC of the studied scoring systems for the outcome of mortality, although the CIs on point estimates of the AUC of the REMS and CURB-65 scores all overlap.

Therapeutic hypothermia protocol in a community emergency department.

OBJECTIVES: Therapeutic hypothermia (TH) has been shown to improve survival and neurological outcome in patients resuscitated after out of hospital cardiac arrest (OHCA) from ventricular fibrillation/ventricular tachycardia (VF/VT). We evaluated the effects of using a TH protocol in a large community hospital emergency department (ED) for all patients with neurological impairment after resuscitated OHCA regardless of presenting rhythm. We hypothesized improved mortality and neurological outcomes without increased complication rates. METHODS: Our TH protocol entails cooling to 33°C for 24 hours with an endovascular catheter. We studied patients treated with this protocol from November 2006 to November 2008. All non-pregnant, unresponsive adult patients resuscitated from any initial rhythm were included. Exclusion criteria were initial hypotension or temperature less than 30°C, trauma, primary intracranial event, and coagulopathy. Control patients treated during the 12 months before the institution of our TH protocol met the same inclusion and exclusion criteria. We recorded survival to hospital discharge, neurological status at discharge, and rates of bleeding, sepsis, pneumonia, renal failure, and dysrhythmias in the first 72 hours of treatment. RESULTS: Mortality rates were 71.1% (95% CI, 56-86%) for 38 patients treated with TH and 72.3% (95% CI 59-86%) for 47 controls. In the TH group, 8% of patients (95% CI, 0-17%) had a good neurological outcome on discharge, compared to 0 (95% CI 0-8%) in the control group. In 17 patients with VF/VT treated with TH, mortality was 47% (95% CI 21-74%) and 18% (95% CI 0-38%) had good neurological outcome; in 9 control patients with VF/VT, mortality was 67% (95% CI 28-100%), and 0% (95% CI 0-30%) had good neurological outcome. The groups were well-matched with respect to sex and age. Complication rates were similar or favored the TH group. CONCLUSION: Instituting a TH protocol for OHCA patients with any presenting rhythm appears safe in a community hospital ED. A trend towards improved neurological outcome in TH patients was seen, but did not reach significance. Patients with VF appeared to derive more benefit from TH than patients with other rhythms.

Dizzy and confused: a step-by-step evaluation of the clinician's favorite chief complaint.

This article covers the general approach to patients who present to the emergency department with a complaint of dizziness or vertigo, and altered mentation. Patients' histories and physical examination findings are discussed first, then a pertinent differential diagnosis, ranging from neurological causes and poor perfusion states to toxicologic causes, is described along with the distinguishing features and potential diagnostic pitfalls of each problem. Case scenarios are presented and the treatment and disposition of patients from the emergency department are discussed.

Evaluation of a modified early goal-directed therapy protocol.

OBJECTIVES: The study aimed to determine mortality in septic patients 2 years after introduction of a modified early goal-directed therapy (EGDT) protocol and to measure compliance with the protocol. DESIGN: This was an observational study of prospectively identified patients treated with EGDT in our emergency department (ED) from May 2007 through May 2008 and compared with retrospectively obtained data on patients treated before protocol implementation, from May 2004 to May 2005. SETTING: This study was conducted at a large tertiary-care suburban community hospital with more than 85 000 ED visits annually and 700 inpatient beds. PATIENTS: Patients with severe sepsis or septic shock were included in the study. INTERVENTIONS: A modified EGDT protocol was implemented. MEASUREMENTS AND MAIN RESULTS: A total of 216 patients were treated with our EGDT protocol, with 32.9% mortality (95% confidence interval [CI], 26.6%-39.2%); 183 patients (84.7%) had septic shock, with a mortality of 34.4% (95% CI, 28%-41%). Our control group of 205 patients had a 27.3% mortality (95% CI, 21.2%-33.5%), of which 123 had septic shock with a mortality of 43.1% (95% CI, 34%-52%). Early goal-directed therapy protocol compliance was as follows: 99% received adequate intravenous fluids, 99% had a central line, 98% had antibiotics in the first 6 hours, 28% had central oxygen saturation measured, 3.7% received dobutamine, and 19% were transfused blood. CONCLUSIONS: Although we found a trend toward decreased mortality in patients with septic shock treated with EGDT, with an absolute difference of 8.7%, this difference was not statistically significant. Compliance with individual elements of the protocol was variable.

A rapid quantitative turbimetric d-dimer assay has high sensitivity for detection of pulmonary embolism in the ED.

Many rapid d-dimer assays are commercially available with wide ranges of reported sensitivities, often based on small sample sizes. This has limited their intended use as rapid and inexpensive tests to evaluate pulmonary embolism in the low-risk patient. We sought to determine the sensitivity of the STA-Liatest D-Di d-dimer assay in our ED. We performed a retrospective analysis of 103 patients seen in our ED with the admitting diagnosis of known or suspected pulmonary embolism. These charts were assessed to establish if a d-dimer assay was performed within 24 hours. These charts were then reviewed to determine what diagnostic studies were performed and what final diagnosis was reached. Of the 103 charts identified, 55 had d-dimer assays performed within 24 hours. Of those, 38 were diagnosed with pulmonary embolism; none had negative d-dimer assays (<400 ng/mL). Using the exact method, the sensitivity of this assay was calculated to be 100% with a 95% confidence interval (CI) of 91.4% to 100%. Our results suggest that the STA-Liatest D-Di d-dimer assay could have an adequate sensitivity to be used to rule out pulmonary embolism in low-risk patients. Further prospective studies with larger sample sizes are required to validate this observation.