The MIMO clinical trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. Atrial ...fibrillation (AF) is a common comorbidity in heart failure and affects patient's outcome.
The primary endpoint of this substudy is to know if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. The first secondary endpoint is to know if AF modified the reduced risk of serious adverse events or death at 30 days in the midazolam arm. The second secondary objective of this substudy is to analyze whether AF modified the reduced risk of midazolam against morphine on the total number of serious adverse events per patient.
We conducted a secondary analysis of the MIMO trial. Patients more than 18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine.
In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without AF. Calculating the Cochran-Mantel-Haenszel interaction test, we evaluated if AF modified the reduced risk of serious adverse events in the midazolam arm compared to morphine.
One hundred eleven patients (median = 78.9 years; IQR, 72.3-83.7; women, 52.2%) were randomized in the MIMO trial, 55 to receive midazolam and 56 to morphine. All randomized patients received the assigned drug and there were no losses to follow-up. Forty-four patients (39.6%) had AF. In the AF group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.42 (95% CI, 0.14-1.3). In the group without AF, the RR was 0.46 (95% CI, 0.21-1). The presence of AF did not modify the reduced risk of serious adverse events in the midazolam arm compared with morphine ( P for interaction = 0.88).
This post hoc analysis of the MIMO trial suggests that the reduced risk of serious adverse events in the midazolam group compared to morphine is similar in patients with and without AF.
We investigated the incidence, clinical characteristics, risk factors, and outcome of meningoencephalitis (ME) in patients with COVID-19 attending emergency departments (ED), before hospitalization. ...We retrospectively reviewed all COVID patients diagnosed with ME in 61 Spanish EDs (20% of Spanish EDs, COVID-ME) during the COVID pandemic. We formed two control groups: non-COVID patients with ME (non-COVID-ME) and COVID patients without ME (COVID-non-ME). Unadjusted comparisons between cases and controls were performed regarding 57 baseline and clinical characteristics and 4 outcomes. Cerebrospinal fluid (CSF) biochemical and serologic findings of COVID-ME and non-COVID-ME were also investigated. We identified 29 ME in 71,904 patients with COVID-19 attending EDs (0.40‰, 95%CI=0.27–0.58). This incidence was higher than that observed in non-COVID patients (150/1,358,134, 0.11‰, 95%CI=0.09–0.13; OR=3.65, 95%CI=2.45–5.44). With respect to non-COVID-ME, COVID-ME more frequently had dyspnea and chest X-ray abnormalities, and neck stiffness was less frequent (OR=0.3, 95%CI=0.1–0.9). In 69.0% of COVID-ME, CSF cells were predominantly lymphocytes, and SARS-CoV-2 antigen was detected by RT-PCR in 1 patient. The clinical characteristics associated with a higher risk of presenting ME in COVID patients were vomiting (OR=3.7, 95%CI=1.4–10.2), headache (OR=24.7, 95%CI=10.2–60.1), and altered mental status (OR=12.9, 95%CI=6.6–25.0). COVID-ME patients had a higher in-hospital mortality than non-COVID-ME patients (OR=2.26; 95%CI=1.04–4.48), and a higher need for hospitalization (OR=8.02; 95%CI=1.19–66.7) and intensive care admission (OR=5.89; 95%CI=3.12–11.14) than COVID-non-ME patients. ME is an unusual form of COVID presentation (<0.5‰ cases), but is more than 4-fold more frequent than in non-COVID patients attending the ED. As the majority of these MEs had lymphocytic predominance and in one patient SARS-CoV-2 antigen was detected in CSF, SARS-CoV-2 could be the cause of most of the cases observed. COVID-ME patients had a higher unadjusted in-hospital mortality than non-COVID-ME patients.
The midazolam vs morphine (MIMO) trial showed that patients treated with midazolam had fewer serious adverse events than those treated with morphine. In many patients with acute pulmonary edema, the ...left ventricular ejection fraction (LVEF) is preserved, at 50% or higher. We aimed to determine whether left ventricular (LV) systolic dysfunction (D), defined by an LVEF of less than 50%, modifies the protective effect of midazolam vs morphine.
The MIMO trial randomized 111 patients with acute pulmonary edema to receive intravenous midazolam in 1-mg doses to a maximum of 3 mg (n = 55) or morphine in 2- to 4-mg doses to a maximum of 8 mg (n= 56). We calculated the relative risk (RR) for a serious adverse event in patients with and without systolic LVD.
LVEF was preserved in 84 (75.7%) of the patients with acute pulmonary edema. In patients with systolic LVD, 4 patients (26.9%) in the midazolam arm vs 6 (50%) in the morphine arm developed serious adverse events (RR, 0.53; 95% CI, 0.2-1.4). In patients without systolic LVD, 6 patients (15%) in the midazolam arm vs 18 (40.9%) in the morphine arm experienced such events (RR, 0.37; 95% CI, 0.16-0.83). The presence of systolic LVD did not modify the protective effect of midazolam on serious adverse effects (P=.57).
The effect of midazolam vs morphine in protecting against the development of serious adverse events or death is similar in patients with and without systolic LVD.
Acquired or immune thrombotic thrombocytopenic purpura (TTP) are thrombotic microangiopathies associated with high mortality if treatment is not started early. Onset is usually sudden, meaning that ...the condition is often diagnosed in hospital emergency departments, where TTP must be suspected as early as possible. These guidelines were drafted by specialists in emergency medicine and hematology to cover the diagnosis, referral, and treatment of patients suspected of immune-mediated TTP who require emergency care. Immune TTP should be suspected whenever a patient presents with hemolytic microangiopathy and has a negative Coombs test, and thrombocytopenia, possibly in conjunction with fever and neurologic and cardiac alterations. If one of the existing diagnostic algorithms indicates there is a high probability that the patient has immune TTP, plasma exchange therapy should be started along with immunosuppressants. Treatment with caplacizumab should also be considered. The patient should be referred immediately to the hematology department within the same hospital or a referral hospital.
The Surviving Sepsis Campaign (SSC) published a 2021 update of its 2016 recommendations. The update was awaited with great anticipation the world over, especially by emergency physicians. Under the ...framework of the CIMU 2022 (33rd World Emergency Medicine Conference) in Guadalajara, Mexico in March, emergency physiciansreviewed and analyzed the 2021 SSC guidelines from our specialty's point of view. In this article, the expert reviewers present their consensus on certain key points of most interest in emergency settings at this time. The main aims of the review are to present constructive comments on 10 key points and/or recommendations in the SSC 2021 update and to offer emergency physicians' experience- and evidence-based proposals. Secondarily, the review's recommendations are a starting point for guidelines to detect severe sepsis in emergency department patients and prevent progression, which is ultimate goal of what has become known as the Guadalajara Declaration on sepsis.
To estimate incidence, risk factors, clinical characteristics and outcomes of acute (myo)pericarditis (AMP) in patients with COVID-19.
Case-control, retrospective review, consecutive case inclusion ...performed in 62 Spanish EDs. All COVID-19 patients with AMP (cases) were compared in clinical characteristics and outcomes with COVID-19 without AMP (control group A) and non-COVID patients with AMP (control group B). We estimated unadjusted standardised incidence (SI, not adjusted by population's age/sex) of AMP in COVID-19 and non-COVID populations (per 100 000/year).
We identified 67 AMP in COVID-19 patients (SI=56.5, OR with respect to non-COVID patients=4.43, 95% CI=3.98 to 4.94). Remarkably, COVID-19 cases presented with chest pain less frequently than non-COVID patients and had less typical ECG changes, higher NT-proBNP (N-terminal prohormone of brain natriuretic peptide), more left and right ventricular dysfunction in echocardiography and more need of inotropic/vasopressor drugs. Admission to intensive care was higher than control group A (OR=3.22, 95% CI=1.43 to 7.23), and in-hospital mortality was higher than control group B (OR=7.75, 95% CI=2.77 to 21.7).
AMP is unusual as a form of COVID-19 presentation (about 1‰ cases), but SI is more than fourfold higher than non-COVID population, and it is less symptomatic, more severe and has higher in-hospital mortality; therefore, rapid recognition, echocardiographic assessment of myopericardial inflammation/dysfunction and treatment with vasoactive drugs when needed are recommended in AMP in patients with COVID-19.
Background: During the first wave of the COVID-19
pandemic, the availability of a critical care bed was insufficient.
The aim of this work was to evaluate the presence of
protocols, management in the ...emergency department (ED)
and the availability of intensive care unit (ICU) beds for severe
COVID-19 patients attended in Spanish hospital EDs
during the first peak of the 2020 pandemic.
Methods: Questionnaire collecting data regarding ED
care in March-April 2020 aimed at all Spanish public health
care EDs. The respondents were the Chiefs of EDs. The
variables of interest were: 1) Presence and of compliance
with ED protocols for decision making and adequacy
of therapeutic effort; 2) management of COVID-19 patients
with non-invasive mechanical ventilation (NIMV) or
high flow nasal cannula (HFNC) in the ED; and 3) ICU bed
accessibility for ED patients. The results were compared
based on the characteristics of the hospital, impact of the
pandemic and autonomous community. A descriptive and
inferential analysis of the variables studied was performed
using the chi-square test and analysis of variance.
Results: A total of 246 questionnaires (89%) were
received. Protocols were available in 136 EDs (57.1%).
Globally, the protocol was applied in >95% of the EDs,
although this was less frequent (76%) in EDs with high
impact of the pandemic. 53% of the EDs managed patients
with severe COVID-19 with NIMV/HFNC in the
ED itself, and 19.4% suffered from lack of ICU beds. The
lack of ICU beds for severe COVID-19 patients in the ED
significantly differed among periods, and more marked in
hospitals with ICU and with high pandemic impact.
Conclusions: it is needed to generalize the implementation
of protocols in EDs for the management of severe
COVID-19 patients and improve the capacity of the
ICUs to homogeneously adjust to the needs.
Fundamentos: Durante la primera oleada de la
pandemia por COVID-19 la disponibilidad de una cama
de críticos fue insuficiente. El objetivo de este estudio
fue evaluar la existencia de protocolos, el manejo en
Urgencias y la disponibilidad de camas en las Unidades
de Cuidados Intensivos (UCI) para pacientes graves
por COVID-19 atendidos en los Servicios de Urgencias
Hospitalarias (SUH) españoles durante la primera ola
pandémica de 2020.
Métodos: Se realizó una encuesta que recabó datos
referentes a marzo-abril de 2020 de los SUH españoles
del Sistema Público de Salud. El encuestado fue el responsable
del SUH. Las variables de interés fueron: 1)
Existencia y grado de cumplimiento en el SUH de los
protocolos para la toma de decisiones y la adecuación del
esfuerzo terapéutico; 2) manejo en el SUH de pacientes
con COVID-19 mediante ventilación mecánica no invasiva
(VMNI) u oxigenoterapia con cánula nasal de alto
flujo (CNAF); y 3) accesibilidad a una cama de UCI. Se
compararon los resultados según características hospitalarias,
impacto de la pandemia y comunidad autónoma.
Se realizó un análisis descriptivo e inferencial de las variables
estudiadas mediante test de ji cuadrado y análisis
de la varianza.
Resultados: Se recibieron 246 encuestas (89%) y
136 SUH (57,1%) dispusieron de protocolo propio. El
95% de los SUH aplicaron el protocolo siempre o con alguna
excepción, aunque significativamente menos (76%)
en los de mayor impacto pandémico. El 53% de los SUH
manejaron pacientes graves por COVID-19 con VMNI/
CNAF. El 19,4% de los SUH tuvo insuficiencia de camas
de críticos (la mayor parte del tiempo o con cierta frecuencia),
mayor en los SUH con alto impacto pandémico y con
diferencias estadísticamente significativas entre periodos.
Conclusiones: Debería generalizarse la adopción
de protocolos para el manejo de pacientes graves por
COVID-19 y ajustar la capacidad de las UCI a las necesidades
de cada momento de forma homogénea.
The COPD Assessment Test (CAT) measures quality of life in patients with chronic obstructive pulmonary disease (COPD) as well as disease impact on activities of daily living. The questionnaire ...consists of 8 items related to breathing (cough, phlegm, chest tightness, and breathlessness) and other symptoms (low energy level, sleep disturbances, limitations on daily activities, and confidence when leaving the home). We investigated the relative impact of respiratory versus nonrespiratory scoring on the total CAT score at different moments in the course of COPD exacerbations: baseline (24 hours before an exacerbation), during the exacerbation, 15 days later, and 2 months later. To assess the influence of the respiratory item score on decisions to hospitalize patients treated for exacerbated COPD in our hospital emergency department (ED).
Prospective cohort study. We recruited patients who came to our ED for symptoms consistent with exacerbated COPD. Sociodemographic and clinical data were recorded. Clinical information, including treatments pleustarted in the ED and CAT scores, were also recorded. The event was defined as highly symptomatic if the patient's score was 3 points or higher on at least 3 of the 4 respiratory items at baseline. The outcome measures for the first objective were the total CAT score and item scores at the 4 time points before (baseline), during (ED), and after the exacerbation. The outcome for the second objective was hospital admission.
A total of 587 patients were included. The mean (SD) total CAT score was 13.48 (7.29) at baseline, 24.86 (7.25) in the ED, 14.7 (7.47) at 15 days, and 13.45 (7.36) at 2 months. The respiratory item scores accounted for a mean 53.4% (20.76%) of the total score at baseline and 48.2% (11.47%) of the total score in the ED. Eighty-two patients (14.0%) were classified as being highly symptomatic. A total of 359 (61.2%) were admitted. Predictors of hospital admission were classification as highly symptomatic, odds ratio (OR, 3.045; 95% CI, 1.585-5.852, P .001), dyspnea at rest (OR, 2.906; 95% CI:1.943-4.346, P .001), and start of the following treatments in the ED: oxygen therapy (OR, 4.550; 95% CI, 3.056-6.773; P .0001), diuretic (OR, 1.754; 95% CI, 1.091-2.819; P = .02), and intravenous antibiotics (OR, 1.536; 95% CI, 1.034-2.281; P = .03). The model achieved an area under the receiver operating characteristic curve of 0.80 (95% CI, 0.763-0.836).
Hospital admission from the ED is highly likely in patients with COPD exacerbation who have high baseline CAT scores, dyspnea at rest in the ED, and require oxygen therapy, diuretics, or intravenous antibiotics in the ED. The total CAT score and scores on respiratory items provide a tool for tailoring pharmacalogic and nonpharmacologic treaments and can facilitate follow-up evaluations.
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