Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department.

INTRODUCTION: Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM). METHODS: We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining \u3e100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel. RESULTS: The data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted. CONCLUSION: This survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use

Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

Objectives:  The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding? Methods:  MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies. Results:  Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%). Conclusions:  Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis

Leukocytosis as Prognostic Indicator of Major Injury

Objective To test the diagnostic use of the triage white blood cell (WBC) count in differentiating major from minor injuries. Methods We conducted a retrospective study of a prospectively collected database of trauma patients 13 years of age or older at a Level I trauma center from January 2005 through December 2008. We excluded all patients with obvious life-threatening injuries requiring immediate surgery, isolated head trauma, transferred from another institution or dead on arrival. We recorded age, sex, injury mechanism, vital signs, WBC, base deficit (BD), lactate (LAC) and calculated injury severity scores (ISS). Major injury was defined as either a change in hematocrit \u3e10 points or blood transfused within 24 hours, or ISS \u3e15. Results 805 patients were included in the study with an average age of 38.6 years (Range 13–95 yrs) years. 75.3% of patients were male, 45.6% had blunt and 34.4% had penetrating trauma. For vital signs, blood pressure was not significantly different between major and minor injury patients. Major compared to minor injury patients had a statistically but not clinically significant higher heart rate. Major injury patients had significantly (p \u3c 0.0001) higher WBC count (10.53 K/μl, 95% CI: 9.7–11.3) compared to patients with minor injuries (8.92 K/μl, 95% CI: 8.7–9.2), but both were in the normal range. Patients with major compared to minor injury had significantly (p \u3c 0.0001) higher BD (−3.1 versus −0.027 mmol/L) and higher LAC (3.9 versus 2.48 mmol/L). Areas under the curve for WBC count (0.60, 95% CI: 0.54–0.66) are similar to BD (0.69, 95% CI: 0.63–0.74) and LAC (0.66, 95% CI: 0.60–0.71). Conclusion WBC count is not a useful addition as a diagnostic indicator of major trauma in our study population

Is Experienced Physician Gestalt With an Electrocardiogram Sufficient to Accurately Exclude Acute Myocardial Infarction in a Patient With Suspected Acute Coronary Syndrome?

VoRSUNY DownstateEmergency MedicineN/

Antidysrhythmic drug therapy for the termination of stable, monomorphic ventricular tachycardia: a systematic review.

We performed a systematic review of the literature to compare the efficacy of different drug therapies for the termination of stable, monomorphic ventricular tachycardia (VT).We searched EMBASE, MEDLINE and Cochrane for trials from 1965 through July 2013 using a search strategy derived from the following clinical question in PICO format:Adults (≥18 years) with stable monomorphic VT;Intravenous antidysrhythmic drug; Comparator: Intravenous lidocaine or amiodarone;Termination of VT. For all drug comparisons, we calculated relative risks (RR; 95% CI) and number needed to treat (NNT, 95% CI) between drugs. We also evaluated the methodological quality of the studies.Our search yielded 219 articles by PubMed and 390 articles by EMBASE. 3 prospective studies (n=93 patients) and 2 retrospective studies (n=173 patients) met our inclusion and exclusion criteria. From the prospective studies, RR of VT termination of procainamide versus lidocaine was 3.7 (1.3-10.5); ajmaline versus lidocaine, RR=5.3 (1.4-20.5); and sotalol versus lidocaine, RR=3.9 (1.3-11.5). From the retrospective studies: procainamide versus lidocaine, RR=2.2 (1.2-4.0); and procainamide versus amiodarone RR=4.3 (0.8-23.6). All 5 reviewed studies had quality issues, including potential bias for randomisation and concealment.Based on limited available evidence from small heterogeneous human studies, for the treatment of stable, monomorphic VT, procainamide, ajmaline and sotalol were all superior to lidocaine; amiodarone was not more effective than procainamide.AMSUNY DownstateEmergency MedicineN/

Pharmacologic Cardioversion of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department: A Systematic Review and Network Meta-analysis.

We conduct a systematic review and Bayesian network meta-analysis to indirectly compare and rank antidysrhythmic drugs for pharmacologic cardioversion of recent-onset atrial fibrillation and atrial flutter in the emergency department (ED).We searched MEDLINE, EMBASE, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with recent-onset atrial fibrillation or atrial flutter and compared antidysrhythmic agents, placebo, or control. We determined these outcomes before data extraction: rate of conversion to sinus rhythm within 4 hours, time to cardioversion, rate of significant adverse events, and rate of thromboembolism within 30 days. We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses network meta-analysis and appraised selected trials with the Cochrane review handbook.The systematic review initially identified 640 studies; 19 met inclusion criteria. Eighteen trials that randomized 2,069 atrial fibrillation patients provided data for atrial fibrillation conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that antazoline (odds ratio [OR] 24.9; 95% credible interval [CrI] 7.4 to 107.8), tedisamil (OR 12.0; 95% CrI 4.3 to 43.8), vernakalant (OR 7.5; 95% CrI 3.1 to 18.6), propafenone (OR 6.8; 95% CrI 3.6 to 13.8), flecainide (OR 6.1; 95% CrI 2.9 to 13.2), and ibutilide (OR 4.1; 95% CrI 1.8 to 9.6) were associated with increased likelihood of conversion within 4 hours compared with placebo or control. Overall quality was low, and the network exhibited inconsistency.For pharmacologic cardioversion of recent-onset atrial fibrillation within a 4-hour ED visit, there is insufficient evidence to determine which treatment is superior. Several agents are associated with increased likelihood of conversion within 4 hours compared with placebo or control. Limited data preclude any recommendation for cardioversion of recent-onset atrial flutter. Further high-quality study is necessary.AMSUNY DownstateEmergency MedicineN/

Pharmacologic cardioversion of recent-onset atrial fibrillation: a systematic review and network meta-analysis.

We sought to identify the most effective antidysrhythmic drug for pharmacologic cardioversion of recent-onset atrial fibrillation (AF).We searched MEDLINE, Embase, and Web of Science from inception to March 2019, limited to human subjects and English language. We also searched for unpublished data. We limited studies to randomized controlled trials that enrolled adult patients with AF ≤ 48 h and compared antidysrhythmic agents, placebo, or control. We determined these outcomes prior to data extraction: (i) rate of conversion to sinus rhythm within 24 h, (ii) time to cardioversion to sinus rhythm, (iii) rate of significant adverse events, and (iv) rate of thromboembolism within 30 days. We extracted data according to PRISMA-NMA and appraised selected trials using the Cochrane review handbook. The systematic review initially identified 640 studies; 30 met inclusion criteria. Twenty-one trials that randomized 2785 patients provided efficacy data for the conversion rate outcome. Bayesian network meta-analysis using a random-effects model demonstrated that ranolazine + amiodarone intravenous (IV) [odds ratio (OR) 39.8, 95% credible interval (CrI) 8.3-203.1], vernakalant (OR 22.9, 95% CrI 3.7-146.3), flecainide (OR 16.9, 95% CrI 4.1-73.3), amiodarone oral (OR 10.2, 95% CrI 3.1-36.0), ibutilide (OR 7.9, 95% CrI 1.2-52.5), amiodarone IV (OR 5.4, 95% CrI 2.1-14.6), and propafenone (OR 4.1, 95% CrI 1.7-10.5) were associated with significantly increased likelihood of conversion within 24 h when compared to placebo/control. Overall quality was low, and the network exhibited inconsistency. Probabilistic analysis ranked vernakalant and flecainide high and propafenone and amiodarone IV low.For pharmacologic cardioversion of recent-onset AF within 24 h, there is insufficient evidence to determine which treatment is superior. Vernakalant and flecainide may be relatively more efficacious agents. Propafenone and IV amiodarone may be relatively less efficacious. Further high-quality study is necessary.AMSUNY DownstateEmergency MedicineN/

Overdiagnosis and overtreatment of infectious diseases at the intersection of individual disease diagnosis, treatment, and public health

VoRSUNY DownstateN/

A consensus parameter for the evaluation and management of angioedema in the emergency department

Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM)