Acad Emerg Med

Background: Emergency tracheal intubation is associated with a risk of clinical adverse events, including the risk of first-attempt failure. Induction agents usually include a sedative and a neuromuscular blocking agent (i.e., paralytic). Whether the order of administration (i.e., sedative vs. paralytic given first) is associated with first-attempt failure or adverse events is unknown. Methods: This study analyzed data from a single-center prospective cohort collected from 2021 to 2024 at Hennepin County Medical Center, which included all patients undergoing orotracheal intubation in the emergency department. Patients with no detail on administration sequence order were excluded. A Bayesian logistic regression analysis was used to measure the effect of drug sequence order (sedative first vs. paralytic first). The primary outcome was first-attempt failure. The key secondary outcome was peri-intubation hypoxemia (SpO2 < 90%). We estimated the odds ratio (OR), 95% credible interval (CrI), and the probability that the OR was inferior to 1 (existence of an effect) and inferior to 0.9 (significant effect). Frequentist analysis and reanalysis with various priors were performed as sensitivity analyses. Results: A total of 2216 patients were included for analysis. The most frequently used sedative and paralytic agents were etomidate (88.9%) and rocuronium (77.8%), respectively. The paralytic was given first to 56.6% of the patients. After adjustment for age, sex, body mass index, and sedative and paralytic agents, the OR for a paralytic-first strategy for first-attempt failure was 0.73 (95% CrI 0.46–1.02). The probability that the OR was less than 1 was estimated at 95.7% and less than 0.9 at 87.6%. There was a 33.5% and 8.0% probability that administering the paralytic first resulted in an OR < 1 and OR < 0.9 for the risk of hypoxemia, respectively. Sensitivity analyses were consistent with the main results. Conclusions: In this Bayesian analysis a paralytic-first drug sequence was associated with reduced first-attempt failure during emergency tracheal intubation. © 2024 The Author(s). Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Deadly Partners: Interdependence of Alcohol and Trauma in the Clinical Setting

Trauma is the leading cause of death for Americans aged 1 to 45. Over a third of all fatal motor vehicle collisions and nearly eighty percent of completed suicides involve alcohol. Alcohol can be both a cause of traumatic injury as well as a confounding factor in the diagnosis and treatment of the injured patient. Fortunately, brief interventions after alcohol-related traumatic events have been shown to decrease both trauma recidivism and long-term alcohol use. This review will address the epidemiology of alcohol-related trauma, the influence of alcohol on mortality and other outcomes, and the role of prevention in alcohol-related trauma, within the confines of the clinical setting

Early Serial Echocardiographic and Ultrasonographic Findings in Critically Ill Patients With COVID-19.

BACKGROUND: Cardiac function of critically ill patients with COVID-19 generally has been reported from clinically obtained data. Echocardiographic deformation imaging can identify ventricular dysfunction missed by traditional echocardiographic assessment. RESEARCH QUESTION: What is the prevalence of ventricular dysfunction and what are its implications for the natural history of critical COVID-19? STUDY DESIGN AND METHODS: This is a multicenter prospective cohort of critically ill patients with COVID-19. We performed serial echocardiography and lower extremity vascular ultrasound on hospitalization days 1, 3, and 8. We defined left ventricular (LV) dysfunction as the absolute value of longitudinal strain of&nbsp;&lt; 17%&nbsp;or left ventricle ejection fraction (LVEF) of&nbsp;&lt; 50%. Primary clinical outcome was inpatient survival. RESULTS: We enrolled 110 patients. Thirty-nine (35.5%) died before hospital discharge. LV dysfunction was present at admission in 38 patients (34.5%) and in 21 patients (36.2%) on day 8 (P&nbsp;= .59). Median baseline LVEF was 62%&nbsp;(interquartile range [IQR], 52%-69%), whereas median absolute value of baseline LV strain was 16%&nbsp;(IQR, 14%-19%). Survivors and nonsurvivors did not differ statistically significantly with respect to day 1 LV strain (17.9%&nbsp;vs&nbsp;14.4%; P&nbsp;= .12) or day 1 LVEF (60.5%&nbsp;vs&nbsp;65%; P&nbsp;= .06). Nonsurvivors showed worse day 1 right ventricle (RV) strain than survivors (16.3%&nbsp;vs&nbsp;21.2%; P&nbsp;= .04). INTERPRETATION: Among patients with critical COVID-19, LV and RV dysfunction is common, frequently identified only through deformation imaging, and early (day 1) RV dysfunction may be associated with clinical outcome

Australian health care providers' views on opt-out HIV testing

Background: Opt-out HIV testing is a novel concept in Australia. In the opt-out approach, health care providers (HCPs) routinely test patients for HIV unless they explicitly decline or defer. Opt-out HIV testing is only performed with the patients' consent, but pre-test counselling is abbreviated. Australian national testing guidelines do not currently recommend opt-out HIV testing for the general population. Non-traditional approaches to HIV testing (such as opt-out) could identify HIV infections and facilitate earlier treatment, which is particularly important now that HIV is a chronic, manageable disease. Our aim was to explore HCPs' attitudes toward opt-out HIV testing in an Australian context, to further understanding of its acceptability and feasibility. Methods: In this qualitative study, we used purposeful sampling to recruit HCPs who were likely to have experience with HIV testing in Western Australia. We interviewed them using a semi-structured guide and used content analysis as per Graneheim to code the data. Codes were then merged into subcategories and finally themes that unified the underlying concepts. We refined these themes through discussion among the research team. Results: Twenty four HCPs participated. Eleven participants had a questioning attitude toward opt-out HIV testing, while eleven favoured the approach. The remaining two participants had more nuanced perspectives that incorporated some characteristics of the questioning and favouring attitudes. Participants' views about opt-out HIV testing largely fell into two contrasting themes: normalisation and routinisation versus exceptionalism; and a need for proof versus openness to new approaches. Conclusion: Most HCPs in this study had dichotomous attitudes toward opt-out HIV testing, reflecting contrasting analytical styles. While some HCPs viewed it favourably, with the perceived benefits outweighing the perceived costs, others preferred to have evidence of efficacy and cost-effectiveness

Interim Estimates of 2024-2025 COVID-19 Vaccine Effectiveness Among Adults Aged ≥18 Years - VISION and IVY Networks, September 2024-January 2025.

COVID-19 vaccination averted approximately 68,000 hospitalizations during the 2023-24 respiratory season. In June 2024, CDC and the Advisory Committee on Immunization Practices (ACIP) recommended that all persons aged ≥6 months receive a 2024-2025 COVID-19 vaccine, which targets Omicron JN.1 and JN.1-derived sublineages. Interim effectiveness of 2024-2025 COVID-19 vaccines was estimated against COVID-19-associated emergency department (ED) or urgent care (UC) visits during September 2024-January 2025 among adults aged ≥18 years in one CDC-funded vaccine effectiveness (VE) network, against COVID-19-associated hospitalization in immunocompetent adults aged ≥65 years in two networks, and against COVID-19-associated hospitalization among adults aged ≥65 years with immunocompromising conditions in one network. Among adults aged ≥18 years, VE against COVID-19-associated ED/UC visits was 33% (95% CI&nbsp;=&nbsp;28%-38%) during the first 7-119 days after vaccination. Among immunocompetent adults aged ≥65 years from two CDC networks, VE estimates against COVID-19-associated hospitalization were 45% (95% CI&nbsp;=&nbsp;36%-53%) and 46% (95% CI&nbsp;=&nbsp;26%-60%) during the first 7-119 days after vaccination. Among adults aged ≥65 years with immunocompromising conditions in one network, VE was 40% (95% CI&nbsp;=&nbsp;21%-54%) during the first 7-119 days after vaccination. These findings demonstrate that vaccination with a 2024-2025 COVID-19 vaccine dose provides additional protection against COVID-19-associated ED/UC encounters and hospitalizations compared with not receiving a 2024-2025 dose and support current CDC and ACIP recommendations that all persons aged ≥6 months receive a 2024-2025 COVID-19 vaccine dose

Comparison of test-negative and syndrome-negative controls in SARS-CoV-2 vaccine effectiveness evaluations for preventing COVID-19 hospitalizations in the United States

BackgroundTest-negative design (TND) studies have produced validated estimates of vaccine effectiveness (VE) for influenza vaccine studies. However, syndrome-negative controls have been proposed for differentiating bias and true estimates in VE evaluations for COVID-19. To understand the use of alternative control groups, we compared characteristics and VE estimates of syndrome-negative and test-negative VE controls.MethodsAdults hospitalized at 21 medical centers in 18 states March 11-August 31, 2021 were eligible for analysis. Case patients had symptomatic acute respiratory infection (ARI) and tested positive for SARS-CoV-2. Control groups were test-negative patients with ARI but negative SARS-CoV-2 testing, and syndrome-negative controls were without ARI and negative SARS-CoV-2 testing. Chi square and Wilcoxon rank sum tests were used to detect differences in baseline characteristics. VE against COVID-19 hospitalization was calculated using logistic regression comparing adjusted odds of prior mRNA vaccination between cases hospitalized with COVID-19 and each control group.Results5811 adults (2726 cases, 1696 test-negative controls, and 1389 syndrome-negative controls) were included. Control groups differed across characteristics including age, race/ethnicity, employment, previous hospitalizations, medical conditions, and immunosuppression. However, control-group-specific VE estimates were very similar. Among immunocompetent patients aged 18-64&nbsp;years, VE was 93&nbsp;% (95&nbsp;% CI: 90-94) using syndrome-negative controls and 91&nbsp;% (95&nbsp;% CI: 88-93) using test-negative controls.ConclusionsDespite demographic and clinical differences between control groups, the use of either control group produced similar VE estimates across age groups and immunosuppression status. These findings support the use of test-negative controls and increase confidence in COVID-19 VE estimates produced by test-negative design studies

Heterogeneous treatment effects of therapeutic-dose heparin in patients hospitalized for COVID-19

Importance Randomized clinical trials (RCTs) of therapeutic-dose heparin in patients hospitalized with COVID-19 produced conflicting results, possibly due to heterogeneity of treatment effect (HTE) across individuals. Better understanding of HTE could facilitate individualized clinical decision-making. Objective To evaluate HTE of therapeutic-dose heparin for patients hospitalized for COVID-19 and to compare approaches to assessing HTE. Design, Setting, and Participants Exploratory analysis of a multiplatform adaptive RCT of therapeutic-dose heparin vs usual care pharmacologic thromboprophylaxis in 3320 patients hospitalized for COVID-19 enrolled in North America, South America, Europe, Asia, and Australia between April 2020 and January 2021. Heterogeneity of treatment effect was assessed 3 ways: using (1) conventional subgroup analyses of baseline characteristics, (2) a multivariable outcome prediction model (risk-based approach), and (3) a multivariable causal forest model (effect-based approach). Analyses primarily used bayesian statistics, consistent with the original trial. Exposures Participants were randomized to therapeutic-dose heparin or usual care pharmacologic thromboprophylaxis. Main Outcomes and Measures Organ support–free days, assigning a value of −1 to those who died in the hospital and the number of days free of cardiovascular or respiratory organ support up to day 21 for those who survived to hospital discharge; and hospital survival. Results Baseline demographic characteristics were similar between patients randomized to therapeutic-dose heparin or usual care (median age, 60 years; 38% female; 32% known non-White race; 45% Hispanic). In the overall multiplatform RCT population, therapeutic-dose heparin was not associated with an increase in organ support–free days (median value for the posterior distribution of the OR, 1.05; 95% credible interval, 0.91-1.22). In conventional subgroup analyses, the effect of therapeutic-dose heparin on organ support–free days differed between patients requiring organ support at baseline or not (median OR, 0.85 vs 1.30; posterior probability of difference in OR, 99.8%), between females and males (median OR, 0.87 vs 1.16; posterior probability of difference in OR, 96.4%), and between patients with lower body mass index (BMI 90% for all comparisons). In risk-based analysis, patients at lowest risk of poor outcome had the highest propensity for benefit from heparin (lowest risk decile: posterior probability of OR >1, 92%) while those at highest risk were most likely to be harmed (highest risk decile: posterior probability of OR <1, 87%). In effect-based analysis, a subset of patients identified at high risk of harm (P = .05 for difference in treatment effect) tended to have high BMI and were more likely to require organ support at baseline. Conclusions and Relevance Among patients hospitalized for COVID-19, the effect of therapeutic-dose heparin was heterogeneous. In all 3 approaches to assessing HTE, heparin was more likely to be beneficial in those who were less severely ill at presentation or had lower BMI and more likely to be harmful in sicker patients and those with higher BMI. The findings illustrate the importance of considering HTE in the design and analysis of RCTs. Trial Registration ClinicalTrials.gov Identifiers: NCT02735707, NCT04505774, NCT04359277, NCT0437258

No Room for Error: Empiric Treatment for Fulminant Pneumonia

Early antibiotic administration is critical in cases of sepsis and severe community-acquired pneumonia, which is frequently due to Streptococcus pneumoniae, Staphylococcus aureus, Legionella species, or influenza. We describe the case of a 29-year-old previously healthy man who presented to an urban emergency department (ED) in the North Central U.S. with fever, hip pain, severe hypoxemia, and diffuse pulmonary infiltrates. He was intubated and received piperacillin/tazobactam, levofloxacin, vancomycin, and oseltamivir; given his fulminant presentation and predicted high mortality, doxycycline, methylprednisolone, and amphotericin B were also administered empirically in the ED. A respiratory culture eventually grew Blastomyces dermatitidis, and the patient survived. Severe acute respiratory distress syndrome due to fulminant pneumonitis carries a high mortality. Faced with this scenario and no room for error, it is important that the emergency physician cover for all possible pathogens, including zoonotic bacteria and endemic fungi