Evaluation of Richmond Agitation Sedation Scale (RASS) in Mechanically Ventilated in the Emergency Department.

The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implementation in mechanically ventilated patients sedated in the emergency department (ED), compliance with RASS, and goal achievement. This study was a retrospective chart review at a large Level I trauma academic medical center. Patients who were intubated in the ED or en route to the ED between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the following criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of 6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62 were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37 patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED. A review of sedation prescribing revealed that 39% received a regimen of varied combinations of continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33% received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment of the RASS was a common practice, but there were inconsistencies in measurement. A limited number of patients achieved their RASS goal in the ED. These results support a provider and nursing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement, and the need for appropriate assessments.

Drug-induced thrombocytopenia after anticoagulation with rivaroxaban.

A 66-year-old man presented to the emergency department with complaints of dark-colored stool and rash developing over the last couple of days. The patient was started on rivaroxaban and flecainide for months prior for atrial fibrillation. Upon arrival, he was awake, alert, and oriented with a blood pressure of 111/63mmHg, heart rate of 68 beats per minute, and oxygen saturation of 96% on room air. A review of systems was unremarkable with the exception of skin rash and light-headedness. The patient's initial laboratory results were significant for red blood cell (RBC) count of 4.05×106/mcL, hemoglobin of 12.1g/dL, hematocrit of 35.6%, and platelet count of 1×103/mcL. Aggressive hydration was started in the ED, initially with two 1-L boluses of normal saline followed by an infusion of 10mL/h. One unit of platelets was transfused. Rivaroxaban and flecainide were held on admission. Twenty-four hours after admission, the patient was initiated on immune globulin (IVIG) Gammagard (Baxter, West Lake, CA), 75g on 3 consecutive days and steroids for possible immune thrombocytopenia. His platelet count steadily improved over the 6-day period to 119×103/mcL on the day of hospital discharge. This is the second reported case of possible rivaroxaban-induced thrombocytopenia.