Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of ...intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka "rescue view").
Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance.
EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI 0.76-0.92) while CLA had the poorest ICC (0.74, 95% CI 0.56-0.85). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs.
Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.
Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants ...intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.
The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated ...Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning.
The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC.
Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention.
CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening.
Background
Cardio‐oncology and emergency medicine are closely collaborative, as many cardiac events in cancer patients require evaluation and treatment in the emergency department (ED). Immune ...checkpoint inhibitors (ICIs) have become a common treatment for patients with head and neck cancer (HNC). However, the immune‐related adverse events (irAEs) from ICIs can be clinically significant.
Methods
We reviewed and analyzed cardiovascular diagnoses among HNC patients who received ICI during the period April 1, 2016–December 31, 2020 in a large tertiary cancer center. Demographics, clinical and cancer‐related data were ed, and billing databases were queried for cardiovascular disease (CVD)‐related diagnosis using International Classification of Disease‐version10 (ICD‐10) codes. We recorded receipt of care at the ED as one of the outcome variables.
Results
A total of 610 HNC patients with a median follow‐up time of 12.3 months (median, interquartile range = 5–30 months) comprised our study cohort. Overall, 25.7% of patients had pre‐existing CVD prior to ICI treatment. Of the remaining 453 patients without pre‐existing CVD, 31.5% (n = 143) had at least one CVD‐related diagnosis after ICI initiation. Tachyarrhythmias (91 new events) was the most frequent CVD‐related diagnosis after ICI. The time to diagnosis of myocarditis from initiation of ICI occurred the earliest (median 2.5 months, 1.5–6.8 months), followed by myocardial infarction (3.7, 0.5–9), cardiomyopathy (4.5, 1.6–7.3), and tachyarrhythmias (4.9, 1.2–11.4). Patients with myocarditis and tachyarrhythmias mainly presented to the ED for care.
Conclusion
The use of ICI in HNC is still expanding and the spectrum of delayed manifestation of ICI‐induced cardiovascular toxicities is yet to be fully defined in HNC survivors.
IntroductionHyperkalaemia is common, life-threatening and often requires emergency department (ED) management; however, no standardised ED treatment protocol exists. Common treatments transiently ...reducing serum potassium (K+) (including albuterol, glucose and insulin) may cause hypoglycaemia. We outline the design and rationale of the Patiromer Utility as an Adjunct Treatment in Patients Needing Urgent Hyperkalaemia Management (PLATINUM) study, which will be the largest ED randomised controlled hyperkalaemia trial ever performed, enabling assessment of a standardised approach to hyperkalaemia management, as well as establishing a new evaluation parameter (net clinical benefit) for acute hyperkalaemia treatment investigations.Methods and analysisPLATINUM is a Phase 4, multicentre, randomised, double-blind, placebo-controlled study in participants who present to the ED at approximately 30 US sites. Approximately 300 adult participants with hyperkalaemia (K+ ≥5.8 mEq/L) will be enrolled. Participants will be randomised 1:1 to receive glucose (25 g intravenously <15 min before insulin), insulin (5 units intravenous bolus) and aerosolised albuterol (10 mg over 30 min), followed by a single oral dose of either 25.2 g patiromer or placebo, with a second dose of patiromer (8.4 g) or placebo after 24 hours. The primary endpoint is net clinical benefit, defined as the mean change in the number of additional interventions less the mean change in serum K+, at hour 6. Secondary endpoints are net clinical benefit at hour 4, proportion of participants without additional K+-related medical interventions, number of additional K+-related interventions and proportion of participants with sustained K+ reduction (K+ ≤5.5 mEq/L). Safety endpoints are the incidence of adverse events, and severity of changes in serum K+ and magnesium.Ethics and disseminationA central Institutional Review Board (IRB) and Ethics Committee provided protocol approval (#20201569), with subsequent approval by local IRBs at each site, and participants will provide written consent. Primary results will be published in peer-reviewed manuscripts promptly following study completion.Trial registration numberNCT04443608.
Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated ...these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time.
Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category.
Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits.
Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.
Purpose
Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in ...providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).
Methods
A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.
Results
During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).
Conclusions
This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.
Purpose
Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study ...to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.
Methods
We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.
Results
The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).
Conclusions
Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.
The number of approved immune checkpoint inhibitors (ICIs) and their indications have significantly increased over the past decade. Immune-related adverse effects (irAEs) of ICIs vary widely in ...presentation and symptoms and can present diagnostic challenges to emergency department (ED) physicians. Moreover, when ICIs are combined with radiotherapy, cytotoxic chemotherapy, or targeted therapy, the attribution of signs and symptoms to an immune-related cause is even more difficult. Here, we report a series of 5 ED cases of adrenal insufficiency in ICI-treated cancer patients. All 5 patients presented with severe fatigue and nausea. Four patients definitely had and one patient possibly had central adrenal insufficiency, and 4 patients had undetectable serum cortisol levels. The majority of the patients had nonspecific symptoms that were not recognized at their first ED presentation. These cases illustrate the need for a heightened level of suspicion for adrenal insufficiency in ICI-treated cancer patients with hypotension, nausea and/or vomiting, abdominal pain, fatigue, or hypoglycemia. As ICI use increases, irAE-associated oncologic emergencies will become more prevalent. Thus, ED physicians must update their knowledge regarding the diagnosis and management of irAEs and routinely inquire about the specific antineoplastic therapies that their ED patients with cancer are receiving. A random cortisol level (results readily available in most EDs) with interpretation taking the circadian rhythm and the current level of physiological stress into consideration can inform the differential diagnosis and whether further investigation of this potential irAE is warranted.
Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management.
To provide a benchmark description of patients who present to ...the ED with active cancer.
This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018.
The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified.
Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean SD pain score, 6.4 2.6 of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics.
This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.
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