Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study.

AIM: Our aim was to test whether a head-to-pelvis CT scan improves diagnostic yield and speed to identify causes for out of hospital circulatory arrest (OHCA). METHODS: CT FIRST was a prospective observational pre-/post-cohort study of patients successfully resuscitated from OHCA. Inclusion criteria included unknown cause for arrest, age >18 years, stability to undergo CT, and no known cardiomyopathy or obstructive coronary artery disease. A head-to-pelvis sudden death CT (SDCT) scan within 6 hours of hospital arrival was added to the standard of care for patients resuscitated from OHCA (post-cohort) and compared to standard of care (SOC) alone (pre-cohort). The primary outcome was SDCT diagnostic yield. Secondary outcomes included time to identifying OHCA cause and time-critical diagnoses, SDCT safety, and survival to hospital discharge. RESULTS: Baseline characteristics between the SDCT (N = 104) and the SOC (N = 143) cohorts were similar. CT scans (either head, chest, and/or abdomen) were ordered in 74 (52%) of SOC patients. Adding SDCT scanning identified 92% of causes for arrest compared to 75% (SOC-cohort; p value < 0.001) and reduced the time to diagnosis by 78% (SDCT 3.1 hours, SOC alone 14.1 hours, p < 0.0001). Identification of critical diagnoses was similar between cohorts, but SDCT reduced delayed (>6 hours) identification of critical diagnoses by 81% (p < 0.001). SDCT safety endpoints were similar including acute kidney injury. Patient survival to discharge was similar between cohorts. DISCUSSION: SDCT scanning early after OHCA resuscitation safely improved the efficiency and diagnostic yield for causes of arrest compared to the standard of care alone. CLINICAL TRIALS NUMBER: NCT03111043.

Prevalence and Patterns of Resuscitation-Associated Injury Detected by Head-to-Pelvis Computed Tomography After Successful Out-of-Hospital Cardiac Arrest Resuscitation.

Background Patients resuscitated from out-of-hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation-associated injuries in a prospective, observational study of a head-to-pelvis sudden-death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation-associated injury was high (81%), including 15 patients (14%) with time-critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P<0.001), but had otherwise similar baseline characteristics and survival compared with those without. Mechanical chest compression systems (27%) had more frequent sternal fractures (36% versus 12%; P=0.009), including displaced fractures (18% versus 1%; P=0.005), but no difference in survival (46% versus 41%; P=0.66). Conclusions In patients resuscitated from OHCA, head-to-pelvis sudden-death computed tomography identified resuscitation injuries in most patients, with nearly 1 in 7 with time-critical complications, and one-half with extensive rib-cage injuries. These data suggest that sudden-death computed tomography may have additional diagnostic utility and treatment implications beyond evaluating causes of OHCA. These important findings need to also be taken in context of the certain fatal outcome without resuscitation efforts. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03111043.

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology.

OBJECTIVES: Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. METHODS: From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. RESULTS: SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. CONCLUSIONS: This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

Diagnostic accuracy of early computed tomographic coronary angiography to detect coronary artery disease after out-of-hospital circulatory arrest.

AIM: To test the diagnostic accuracy of ECG-gated coronary computed tomography angiography (CCTA) to detect coronary artery disease (CAD) among survivors of out-of-hospital circulatory arrest (OHCA). METHODS: We prospectively studied head-to-pelvis computed tomography (CT) scanning (<6 h from hospital arrival) in OHCA survivors. This sub-study tested the primary outcome of CCTA diagnostic accuracy to identify obstructive CAD (≥50% stenosis) compared to clinically-ordered invasive coronary angiography. Patients were not optimized with beta receptor blockade or nitroglycerin. Secondary analyses included CCTA accuracy for CAD in major coronary arteries, obstructive disease at ≥70% stenosis threshold, and where non-evaluable CCTA segments were considered either obstructive or non-obstructive. RESULTS: Of the 104 enrolled OHCA survivors, 28 (27%) received both CT and invasive angiography in this sub study. All CCTA studies were evaluable although 49/346 (14%) individual coronary segments were unevaluable, primarily due to being too small to evaluate (65%). Patient-level diagnostic accuracy for the ≥50% stenosis threshold was high at 0.93 (95% CI 0.77-0.98) with a specificity of 1.0 (95% CI 0.8-1.0), sensitivity of 0.85 (95%CI 0.58-0.96), negative predictive value of 0.88 (95% CI 0.66-0.97) and positive predictive value of 1.0 (0.74-1.0). When non-evaluable segments were considered obstructive, the sensitivity rose to 0.92 (95% CI 0.67-0.99) with lower specificity of 0.27 (95% CI 0.11-0.52). CONCLUSION: Early CCTA of OHCA survivors has high diagnostic accuracy to detect obstructive coronary artery disease. However, the number of non-diagnostic coronary segments is high suggesting further CCTA refinement is needed, such as the pre-CCTA use of nitroglycerin. CLINICAL TRIAL REGISTRATION: NCT03111043 https://clinicaltrials.gov/ct2/show/record/NCT03111043.

Diagnostic yield of non-invasive imaging in patients following non-traumatic out-of-hospital sudden cardiac arrest: A systematic review.

AIM: To review data for non-invasive imaging in the diagnosis of non-traumatic out-of-hospital cardiac arrest (OHCA). DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov databases from inception to January 2017 for studies utilizing non-invasive imaging to identify potential causes of OHCA [computed tomography (CT), ultrasound including echocardiography, and magnetic resonance (MRI)]. STUDY SELECTION: Inclusion criteria were the following: (1) randomized control trials, cohort studies or observational studies; (2) contained a population ≥18 years old with non-traumatic OHCA who underwent diagnostic imaging with CT, MRI, echocardiography, or abdominal ultrasound; (3) imaging was obtained for diagnostic purposes; (4) patients were alive or were undergoing cardiopulmonary resuscitation at the time of imaging; (5) contained potential causes of OHCA. Endpoints studied were the number of potential OHCA causes identified, diagnostic accuracy measures (sensitivity, specificity, positive and negative predictive values), and diagnostic utility (number of imaging findings with reported changes in clinical management). RESULTS: Of the total 5722 studies identified, 17 (0.3%) met inclusion criteria. The majority of studies assessed the utility of CT in OHCA (n=10), and potential causes of OHCA were found in 8-54% of patients following head, abdominal and/or chest CT. Only 1/17 (6%) studies reported diagnostic accuracy measures, and 9/17 (53%) studies included a time to imaging criteria within 24h. CONCLUSION: Although non-invasive imaging is commonly performed in patients after OHCA, its diagnostic utility remains poorly characterized. Prospective studies are needed for appropriate imaging selection and their potential impact on treatment and outcome.

Older adults and high-risk medication administration in the emergency department.

BACKGROUND: Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). PATIENTS AND METHODS: ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. RESULTS: There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). CONCLUSION: Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.

A Sepsis-related Diagnosis Impacts Interventions and Predicts Outcomes for Emergency Patients with Severe Sepsis.

INTRODUCTION: Many patients meeting criteria for severe sepsis are not given a sepsis-related diagnosis by emergency physicians (EP). This study 1) compares emergency department (ED) interventions and in-hospital outcomes among patients with severe sepsis, based on the presence or absence of sepsis-related diagnosis, and 2) assesses how adverse outcomes relate to three-hour sepsis bundle completion among patients fulfilling severe sepsis criteria but not given a sepsis-related diagnosis. METHODS: We performed a retrospective cohort study using patients meeting criteria for severe sepsis at two urban, academic tertiary care centers from March 2015 through May 2015. We included all ED patients with the following: 1) the 1992 Consensus definition of severe sepsis, including two or more systemic inflammatory response syndrome criteria and evidence of organ dysfunction; or 2) physician diagnosis of severe sepsis or septic shock. We excluded patients transferred to or from another hospital and those <18 years old. Patients with an EP-assigned sepsis diagnosis created the "Physician Diagnosis" group; the remaining patients composed the "Consensus Criteria" group. The primary outcome was in-hospital mortality. Secondary outcomes included completed elements of the current three-hour sepsis bundle; non-elective intubation; vasopressor administration; intensive care unit (ICU) admission from the ED; and transfer to the ICU in < 24 hours. We compared proportions of each outcome between groups using the chi-square test, and we also performed a stratified analysis using chi square to assess the association between failure to complete the three-hour bundle and adverse outcomes in each group. RESULTS: Of 418 patients identified with severe sepsis we excluded 54, leaving 364 patients for analysis: 121 "Physician Diagnosis" and 243 "Consensus Criteria." The "Physician Diagnosis" group had a higher in-hospital mortality (12.4% vs 3.3%, P < 0.01) and compliance with the three-hour sepsis bundle (52.1% vs 20.2%, P < 0.01) compared with the "Consensus Criteria" group. An incomplete three-hour sepsis bundle was not associated with a higher incidence of death, intubation, vasopressor use, ICU admission or transfer to the ICU in <24 hours in patients without a sepsis diagnosis. CONCLUSION: "Physician Diagnosis" patients more frequently received sepsis-specific interventions and had a higher incidence of mortality. "Consensus Criteria" patients had infrequent adverse outcomes regardless of three-hour bundle compliance. EPs' sepsis diagnoses reflect risk-stratification beyond the severe sepsis criteria.

The Effect of Computerized Physician Order Entry Template Modifications on the Administration of High-Risk Medications in Older Adults in the Emergency Department.

BACKGROUND: Older adults are more susceptible to adverse events when administered certain medications at doses appropriate for younger adults. OBJECTIVE: The aim of this study was to investigate the effect of default geriatric dosing on computerized physician order entry (CPOE) templates on the subsequent administration of recommended starting doses of opioids, benzodiazepines (BZDs) and non-steroidal anti-inflammatory drugs (NSAIDs) to older adults in the emergency department (ED). METHODS: This was a before-after comparison of the frequency of the recommended starting doses of high-risk medications to adults aged 65 years and older. Computerized records were queried for the administration of the above medication classes in two academic EDs over two similar 4-month periods in 2015 and 2016. Between study periods, the doses of high-risk medications on ED CPOE templates were adjusted for older adults based on established pharmacy guidelines and expert consensus. RESULTS: There was a significant improvement in the rate of recommended dose administration of all medications of interest (27.3 vs. 32.5%, p < 0.001). Not surprisingly, the medications that were maximally impacted were also those most frequently prescribed, with a significant increase in the recommended dosing of opioids (29.0 vs. 35.2%, p < 0.001) accounting for the majority of the change. Although there were no differences in BZDs as a group, there were significant differences in selected BZDs such as midazolam and diazepam. Changes in the recommended dosing of NSAIDs could not be determined due to low numbers of administered doses in both phases of the study. CONCLUSION: Simple changes in the CPOE template resulted in increased administration of the recommended starting doses of high-risk medications to older adults in the ED.

The Effect of Written Posted Instructions on Collection of Clean-Catch Urine Specimens in the Emergency Department.

BACKGROUND: Urinalysis testing is frequently ordered in the emergency department (ED), but contamination of urine specimens limits the interpretation of results. The mid-stream, clean-catch (MSCC) procedure for urine specimen collection is recommended to decrease contamination rates, but without instructions this procedure has poor compliance. OBJECTIVE: To evaluate the effectiveness of written instructions alone, we analyzed the rate of specimen contamination, defined by presence of squamous epithelial cells (SECs) and culture results, in the ED after posting information on the MSCC procedure. METHODS: Instructions in simple English for the MSCC procedure were posted in all patient-accessible restrooms in the ED. Frequency of contamination, defined microscopically as > 5 SECs per high-powered field or through growth of mixed or non-pathologic flora on urine culture, was determined over a 3-month period for comparison to historical controls from the previous year. RESULTS: During the intervention period, 754 urinalyses were sent, with 392 contaminated specimens (51.98%), and 193 urine cultures were sent, with 77 contaminated results (39.8%). Historical controls from the previous year yielded 827 urinalyses sent, with 430 contaminated (51.99%), and 251 urine cultures, with 125 contaminated results (49.8%). The difference between groups was not significant for urinalysis (p = 0.99) or urine culture (p = 0.13). CONCLUSIONS: A poster-based educational intervention with instructions on MSCC procedure failed to decrease contamination rates in this ED-based study. Possible explanations include poor compliance with MSCC technique in the ED, or poor efficacy of this technique at decreasing contamination rates. These results may indicate that other efforts are necessary to improve urine collection methods.

Emergency Medicine Resident Perceptions of Medical Professionalism.

INTRODUCTION: Medical professionalism is a core competency for emergency medicine (EM) trainees; but defining professionalism remains challenging, leading to difficulties creating objectives and performing assessment. Because professionalism is dynamic, culture-specific, and often taught by modeling, an exploration of trainees' perceptions can highlight their educational baseline and elucidate the importance they place on general conventional professionalism domains. To this end, our objective was to assess the relative value EM residents place on traditional components of professionalism. METHODS: We performed a cross-sectional, multi-institutional survey of incoming and graduating EM residents at four programs. The survey was developed using the American Board of Internal Medicine's "Project Professionalism" and the Accreditation Council of Graduate Medical Education definition of professionalism competency. We identified 27 attributes within seven domains: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data to assess variance across attributes as well as differences between residents at different training levels or different institutions. RESULTS: Of the 114 residents eligible, 100 (88%) completed the survey. The relative value assigned to different professional attributes varied considerably, with those in the altruism domain valued significantly lower and those in the "respect for others" and "honor and integrity" valued significantly higher (p<0.001). Significant differences were found between interns and seniors for five attributes primarily in the "duty and service" domain (p<0.05). Among different residencies, significant differences were found with attributes within the "altruism" and "duty and service" domains (p<0.05). CONCLUSION: Residents perceive differences in the relative importance of traditionally defined professional attributes and this may be useful to educators. Explanations for these differences are hypothesized, as are the potential implications for professionalism education. Because teaching professional behavior is taught most effectively via behavior modeling, faculty awareness of resident values and faculty development to address potential gaps may improve professionalism education.

A quality improvement project to improve early sepsis care in the emergency department.

BACKGROUND: Sepsis causes substantial morbidity and mortality in hospitalised patients. Although many studies describe the use of protocols in the management of patients with severe sepsis and septic shock, few have addressed emergency department (ED) screening and management for patients initially presenting with uncomplicated sepsis (ie, patients without organ failure or hypotension). OBJECTIVE: A quality improvement task force at a large, quaternary care referral hospital sought to develop a protocol focusing on early identification of patients with uncomplicated sepsis, in addition to severe sepsis and septic shock. INTERVENTION: The three-tiered intervention consisted of (1) a nurse-driven screening tool and management protocol to identify and initiate early treatment of patients with sepsis, (2) a computer-assisted screening algorithm that generated a 'Sepsis Alert' pop-up screen in the electronic medical record for treating clinical healthcare providers and (3) automated suggested sepsis-specific order sets for initial workup and resuscitation, antibiotic selection and goal-directed therapy. DESIGN: A before and after retrospective cohort study was undertaken to determine the intervention's impact on compliance with recommended sepsis management, including serum lactate measured in the ED, 2 L of intravenous fluid administered within 2 h of triage, antibiotics administered within 3 h of triage and blood cultures drawn before antibiotic administration. Mortality rates for patients in the ED with a sepsis-designated ICD-9 code present on admission were also analysed. RESULTS: Overall bundle compliance increased by 154%, from 28% at baseline to 71% in the last quarter of the study (p<0.001). Bundle, antibiotic and intravenous fluid compliance all increased significantly after launch of the sepsis initiative (eg, bundle and intravenous fluid compliance increased by 74% and 54%, respectively; p<0.001). Bundle and antibiotic compliance both showed further significant increases after implementation of suggested order sets (31% and 25% increases, respectively; p<0.001). The mortality rate for patients in the ED admitted with sepsis was 13.3% before implementation and fell to 11.1% after (p=0.230); mortality in the last two quarters of the study was 9.3% (p=0.107). CONCLUSIONS: The new protocol demonstrates that early screening interventions can lead to expedited delivery of care to patients with sepsis in the ED and could serve as a model for other facilities. Mortality was not significantly improved by our intervention, which included patients with uncomplicated sepsis.

The use of model-based iterative reconstruction to decrease ED radiation exposure.

INTRODUCTION: The radiation risk posed by diagnostic computed tomography (CT) is a growing concern. The use of model-based iterative reconstruction (MBIR) technology reduces radiation exposure but requires additional processing time. The goal of this study was to compare MBIR and a standard CT reconstructive protocols in terms of emergency department (ED) visit duration and reduction in radiation exposure. METHODS: A retrospective, matched, case-control design was used to compare patients who received MBIR and standard protocol abdomen and pelvis CTs. ED length of stay (LOS) and radiation exposure were the 2 primary outcome variables. RESULTS: During the study period, 121 patients met inclusion criteria and were matched to controls for a total of 242 subjects. Although the low-dose group LOS was slightly longer, there was no significant difference in LOS. Mean differences were 18 minutes overall (520 vs 502 minutes; P = .497), 11 minutes for admitted patients (587 vs 576 minutes; P = .839), and 22 minutes for discharged patients (490 vs 468 minutes; P = .482). The mean volume CT dose index for the standard-dose CT was 11.6 ± 8.3 and 7.7 ± 4.6 mGy for the reduced-dose CT, a 34% decrease (P < .001). CONCLUSION: Use of MBIR in the ED may provide decreased radiation exposure while minimally impacting ED LOS.

Emergency department management of delirium in the elderly.

An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.

Lightning injuries.

Lightning is persistently one of the leading causes of death caused by environmental or natural disaster. To understand the pathophysiology and treatment of lightning injuries one must first discount the innumerable myths, superstitions, and misconceptions surrounding lightning. The fundamental difference between high voltage electrical injury and lightning is the duration of exposure to current. Reverse triage should be instituted in lightning strike victims because victims in cardiopulmonary arrest might gain the greatest benefit from resuscitation efforts, although there is no good evidence suggesting that lightning strike victims might benefit from longer than usual resuscitation times. Many of the injuries suffered by lightning strike victims are unique to lightning, and long-term sequelae should be anticipated and addressed in the lightning victim.