Delirium, confusion, or altered mental status as a risk for abnormal head CT in older adults in the emergency department: A systematic review and meta-analysis.

BACKGROUND: Altered mental status (including delirium) is a common presentations among older adults to the emergency department (ED). We aimed to report the association between altered mental status in older ED patients and acute abnormal findings on head computed tomogram (CT). METHODS: A systematic review was conducted using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8th, 2021. We included citations if they described patients aged 65 years or older who received head imaging at the time of ED assessment, and reported whether patients had delirium, confusion, or altered mental status. Screening, data extraction, and bias assessment were performed in duplicate. We estimated the odds ratios (OR) for abnormal neuroimaging in patients with altered mental status. RESULTS: The search strategy identified 3031 unique citations, of which two studies reporting on 909 patients with delirium, confusion or altered mental status were included. No identified study formally assessed for delirium. The OR for abnormal head CT findings in patients with delirium, confusion or altered mental status was 0.35 (95% CI 0.031 to 3.97) compared to patients without delirium, confusion or altered mental status. CONCLUSION: We did not find a statistically significant association between delirium, confusion or altered mental status and abnormal head CT findings in older ED patients.

The National Early Warning Score on admission predicts severe disease and in-hospital mortality of the coronavirus disease 2019 Delta variant: A retrospective cohort study.

Background: Clinical risk scores are widely used in emergency medicine, and some studies have evaluated their use in patients with coronavirus disease 2019 (COVID-19). However, no studies have evaluated their use in patients with the COVID-19 Delta variant. We aimed to study the performance of four different clinical scores (National Early Warning Score [NEWS], quick Sequential Organ Failure Assessment [qSOFA], Confusion, Respiratory rate, Blood pressure, and Age ≥65 [CRB-65], and Kanagawa score) in predicting the risk of severe disease (defined as the need for intubation and in-hospital mortality) in patients with the COVID-19 Delta variant. Methods: This was a retrospective cohort study of patients hospitalized with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta variant infection between June 1 and December 31, 2021. The primary outcomes were the sensitivity and specificity of the aforementioned clinical risk scores at admission to predict severe disease. Areas under the receiver operating characteristic curves (AUROCs) were compared between the clinical risk scores and we identified new cut-off points for all four scores. Results: A total of 249 adult patients were included, of whom 18 developed severe disease. A NEWS ≥7 at admission predicted severe disease with 72.2% sensitivity and 86.2% specificity. The NEWS (AUROC 0.88) was superior to both the qSOFA (AUROC 0.74) and the CRB-65 (AUROC 0.67), and there was no significant difference between the NEWS and Kanagawa score (AUROC 0.86). Conclusion: The NEWS at hospital admission predicted the severity of the COVID-19 Delta variant with high accuracy.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department.

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department.

BACKGROUND: Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED). METHODS: We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects. RESULTS: From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported. CONCLUSIONS: Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

Prevalence and Risk Factors of Insomnia and Sleep-aid Use in Emergency Physicians in Japan: Secondary Analysis of a Nationwide Survey.

INTRODUCTION: Emergency physicians (EP) are suspected to have a high prevalence of insomnia and sleep-aid use. Most prior studies about sleep-aid use in EPs have been limited by low response rates. In this study our aim was to investigate the prevalence of insomnia and sleep-aid use among early-career Japanese EPs and assess the factors associated with insomnia and sleep-aid use. METHODS: We collected anonymous, voluntary, survey-based data regarding chronic insomnia and sleep-aid use from board-eligible EPs taking the initial Japanese Association of Acute Medicine board certification exam in 2019 and 2020. We describe the prevalence of insomnia and sleep-aid use and analyzed demographic and job-related factors using multivariable logistic regression analysis. RESULTS: The response rate was 89.71% (732 of 816). The prevalence of chronic insomnia and sleep-aid use was 24.89% (95% CI 21.78-28.29%) and 23.77% (95% CI 20.69-27.15%), respectively. Factors associated with chronic insomnia were long working hours (odds ratio [OR] 1.02, 1.01-1.03, per one-hour/week), and "stress factor" (OR 1.46, 1.13-1.90). Factors associated with sleep-aid use were male gender (OR 1.71, 1.03-2.86), unmarried status (OR 2.38, 1.39-4.10), and "stress factor" (OR 1.48, 1.13-1.94). The "stress factor" was mostly influenced by stressors in dealing with patients/families and co-workers, concern about medical malpractice, and fatigue. CONCLUSIONS: Early-career EPs in Japan have a high prevalence of chronic insomnia and sleep-aid use. Long working hours and stress were associated with chronic insomnia, while male gender, unmarried status, and stress were associated with the use of sleep aids.

Exploring Teamwork Challenges Perceived by International Medical Graduates in Emergency Medicine Residency.

INTRODUCTION: Non-US international medical graduates (IMG) represent a gradually increasing portion of emergency medicine (EM) residents in the United States. Yet there are no previous studies that explore the needs of this learner population. We conducted a qualitative study to examine non-US IMGs' perceptions of challenges they face specifically regarding team dynamics during their first year of an EM residency. METHOD: Nine non-US IMGs in EM from all over the US participated in anonymous, semi-structured phone interviews lasting 45-60 minutes. We then coded and analyzed the interviews to identify axes and themes using an inductive approach informed by grounded theory. Focused coding and member checking were employed. RESULTS: Non-US IMGs' perceptions of challenges regarding team dynamics during their first year of an EM residency coalesced into two themes: system-based challenges, such as a new power dynamic and understanding the local hospital system, and interpersonal challenges, such as establishing rapport and articulation of critical thinking. CONCLUSION: Non-US IMGs perceived several unique challenges regarding team dynamics during their first year of an EM residency, whether system-based or interpersonal-based. We propose solutions such as a transitional curriculum (as suggested by the participants as well) and cultural-competence training for academic leadership.

Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use. OBJECTIVES: The objective was to evaluate the efficacy and safety of vestibular suppressants in patients with BPPV compared to placebo, no treatment, or canalith repositioning maneuvers (CRMs). METHODS: We searched MEDLINE, Cochrane, EMBASE, and ClinicalTrials.gov from inception until March 25, 2022. for randomized controlled trials (RCTs) comparing antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines to placebo, no treatment, or a CRM. RESULTS: Five RCTs, enrolling 296 patients, were included in the quantitative analysis. We found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up (14-31 days in four studies) when evaluated as a continuous outcome (standardized mean difference -0.03 points, 95% confidence interval [CI] -0.53 to 0.47). Conversely, CRMs may improve symptom resolution at the point of longest follow-up as a dichotomous outcome when compared to vestibular suppressants (relative risk [RR] 0.63, 95% CI 0.52 to 0.78). Vestibular suppressants had an uncertain effect on symptom resolution within 24 h (mean difference [MD] 5 points, 95% CI -16.92 to 26.94), repeat emergency department (ED)/clinic visits (RR 0.37, 95% CI 0.12 to 1.15), patient satisfaction (MD 0 points, 95% CI -1.02 to 1.02), and quality of life (MD -1.2 points, 95% CI -2.96 to 0.56). Vestibular suppressants had an uncertain effect on adverse events. CONCLUSIONS: In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV.

Head computed tomography findings in geriatric emergency department patients with delirium, altered mental status, and confusion: A systematic review.

BACKGROUND: Delirium, altered mental status (AMS), or confusion among older adults are common presentations to the emergency department (ED). We aimed to report the proportion of older ED patients presenting with delirium who have acute abnormal findings on head imaging. We also assessed whether anticoagulation, neurological deficits, trauma, or headache were associated with head imaging abnormalities in these patients. METHODS: A systematic review was performed using Ovid Medline, Embase, Clinicaltrials.gov, Web of Science, and Cochrane Central from conception to April 8, 2021. Citations were included if they described patients aged 65 years or older who received neuroimaging at the time of ED assessment for delirium, confusion, or AMS. Screening, data extraction, and bias assessment were performed in duplicate. The estimated proportion of patients with abnormal neuroimaging and odds ratios (ORs) for each predictor were calculated. RESULTS: The search strategy identified 3014 unique citations, of which six studies reporting on 909 patients with confusion or AMS were included. None of the studies formally diagnosed delirium. Overall, the proportions of older ED patients with AMS or confusion were found to have an abnormal head computed tomography (CT) was 15.6% (95% confidence interval [CI] 7.3%-26.2%). The prevalence of focal neurologic findings was 13.0% (66/506) and for anticoagulation was 9.8% (33/337) among the studies who reported them. The presence of a focal neurological deficit was associated with abnormal head CT (OR 101.8, 95% CI 30.5-340.1). Anticoagulation was not associated with abnormal head CT (OR 1.2, 95% CI 0.4-3.3). No studies reported on the association between headache or trauma and abnormal neuroimaging. CONCLUSIONS: The proportion of abnormal findings on CT neuroimaging in older ED patients with AMS or confusion was 15.6%. The presence of a focal neurological deficit was a strong predictor for the presence of acute abnormality, whereas anticoagulation was not.

Corticosteroids for patients with vestibular neuritis: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department.

BACKGROUND: A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN. METHODS: We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed. RESULTS: From 149 titles, five systematic reviews were selected for quality assessment, and two reviews were of higher methodological quality and were included. These two reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of two RCTs including a total of 50 patients, the use of corticosteroids (compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% confidence interval [CI] 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide CI for the outcome of dizziness handicap score (one study, 30 patients, 20.9 points in corticosteroids group vs. 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low. CONCLUSIONS: There is limited evidence to support the use of corticosteroids for the treatment of VN in the emergency department.

Treatment of pulmonary hypertension associated with COPD: a systematic review.

Chronic obstructive pulmonary disease-associated pulmonary hypertension (COPD-PH) is an increasingly recognised condition which contributes to worsening dyspnoea and poor survival in COPD. It is uncertain whether specific treatment of COPD-PH, including use of medications approved for pulmonary arterial hypertension (PAH), improves clinical outcomes. This systematic review and meta-analysis assesses potential benefits and risks of therapeutic options for COPD-PH. We searched Medline and Embase for relevant publications until September 2020. Articles were screened for studies on treatment of COPD-PH for at least 4 weeks in 10 or more patients. Screening, data extraction, and risk of bias assessment were performed independently in duplicate. When possible, relevant results were pooled using the random effects model. Supplemental long-term oxygen therapy (LTOT) mildly reduced mean pulmonary artery pressure (PAP), slowed progression of PH, and reduced mortality, but other clinical or functional benefits were not assessed. Phosphodiesterase type 5 inhibitors significantly improved systolic PAP (pooled treatment effect -5.9 mmHg; 95% CI -10.3, -1.6), but had inconsistent clinical benefits. Calcium channel blockers and endothelin receptor antagonists had limited haemodynamic, clinical, or survival benefits. Statins had limited clinical benefits despite significantly lowering systolic PAP (pooled treatment effect -4.6 mmHg; 95% CI -6.3, -2.9). This review supports guideline recommendations for LTOT in hypoxaemic COPD-PH patients as well as recommendations against treatment with PAH-targeted medications. Effective treatment of COPD-PH depends upon research into the pathobiology and future high-quality studies comprehensively assessing clinically relevant outcomes are needed.

The emergency neurology literature 2020.

Managing neurological emergencies is an essential element of emergency physicians' armamentarium, irrelevant of the specific nature of their practice. The combination of evolving literature and advances in imaging fuel the rapidly changing standards of care, especially in high-stakes diagnoses such as stroke. Navigating the emergency neurology literature to stay abreast of the current updates is becoming more challenging with the sheer volume of publications, combined with the recent dominance of COVID-19 on the literature and media attention. This review article summarizes emergency neurology literature updates that can help you improve your care of these high-risk presentations; articles covering stroke, dizziness, intracerebral hemorrhage, head trauma imaging, headache, seizures, and COVID-19 are reviewed.

The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section.

BACKGROUND: The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS: The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS: The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION: The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.

Ferritin, fever, and frequent visits: Hyperferritinemic syndromes in the emergency department.

Fever of unknown origin (FUO) is defined as persistent fevers without an identifiable cause despite extensive medical workup. Emergency physicians caring for patients reporting a persistent, nonspecific, febrile illness should carefully consider potentially serious non-infectious causes of FUO. We present a case of a 35-year-old man who presented to the emergency department (ED) three times over a 10-day period for persistent febrile illness and was ultimately diagnosed with Adult-Onset Still's Disease (AOSD) after a serum ferritin level was found to be over 42,000 µg/L. AOSD, along with macrophage activation syndrome, catastrophic antiphospholipid syndrome, and septic shock comprise the four hyperferritinemic syndromes. These are potentially life-threatening febrile illnesses that characteristically present with elevated ferritin levels. In this article, we highlight the value of a serum ferritin level in the workup of a patient with prolonged febrile illness and its utility in facilitating early diagnosis and prompt treatment of hyperferritinemic syndromes in the ED.

Rapid Fire: Acute Brain Failure in Older Emergency Department Patients.

Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.

Genitourinary Emergencies in Older Adults.

Older adults are frequently seen in the emergency department for genitourinary complaints, necessitating that emergency physicians are adept at managing a myriad of genitourinary emergencies. Geriatric patients may present with acute kidney injury, hematuria, or a urinary infection and aspects of how managing these presentations differs from their younger counterparts is emphasized. Older adults may also present with acute urinary retention or urinary incontinence as a result of genitourinary pathology or other systemic etiologies. Finally, genital complaints as they pertain to older adults are briefly highlighted with emphasis on emergent management and appropriate referrals.

The geriatric emergency literature 2020: COVID and beyond.

Older adults are a rapidly growing patient population with unique characteristics and health considerations. Over the past few years, emergency physicians have started to recognize the complexities and importance of Geriatric Emergency Medicine. Several noteworthy elements of their healthcare were brought to the forefront of emergency medicine because this especially vulnerable patient population was disproportionately affected by the pandemic. Clinical topics such as delirium, telehealth, end-of-life care, and elder abuse came into focus; select relevant articles are reviewed. We also highlight equally notable literature which address clinically challenging topics, such as hip fractures and syncope. Finally, articles about improving the experience of and decreasing recidivism in geriatric emergency department patients are reviewed. In short, this review article summarizes geriatric emergency medicine literature that can help you improve your practice while caring for older adults.

Neurologic Emergencies at the Extremes of Age.

The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population.

The geriatric emergency literature 2019.

Geriatric Emergency Medicine is an important frontier for study and innovation by emergency practitioners. The rapid growth of this patient population combined with complex medical and social needs has prompted research ranging from which tests and screening tools are most effective for geriatric evaluation to how we can safely manage pain in the elderly or address goals of care in the Emergency Department. This review summarizes emergency medicine articles focused on the older patient population published in 2019, which the authors consider critical to the practice of geriatric emergency medicine.

Resuscitating the Critically Ill Geriatric Emergency Department Patient.

The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.