Search

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS)., Competing Interests: Jessica S. Whittle has served as a consultant to Vapotherm, Inc., within the last 3 years for the development of educational materials. All compensation totaled less than $1000. Ivan Pavlov has been a speaker for Fisher‐Pakyel within the last 3 years. All compensation was paid to the charitable foundation at the hospital where he works and he did not personally receive any compensation. Alfred D. Sacchetti, Charles Atwood, and Mark S. Rosenberg have no disclosures., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Objective: Advances in medical care have led to a growing population of special needs children who are at risk for suboptimal care when they present to a physician with no previous knowledge of their medical history. This risk may be amplified in the emergency department setting when time-sensitive interventions must be initiated without immediate access to consultants or past records. Our purpose in this study was to evaluate caretakers' knowledge of their children's chronic medical problems and their ability to relate this knowledge to unfamiliar health care providers., Methods: Caretaker/child pairs presenting for specialty visits were surveyed. Questions focused on knowledge of the child's illness, medicine regime, and how to contact the specialist. Chart review confirmed responses of caretakers and provided sociodemographic information. Descriptive statistics and chi2 were used in data analysis., Results: Of the 49 caretakers interviewed, 85% were parents, 53% were African-American, and 43% were Caucasian. One-half of the group received medical assistance. The mean age of the children was 55 months. Responses showed that 53% of caretakers were unable to provide their children's specific diagnoses. Of these, one half could provide a lay diagnosis whereas the remaining one half could only identify the organ system involved or that there was a problem. For children on medications, 29% of caretakers could not provide an accurate list. Name of the subspecialist and phone number of the subspecialty clinic was unknown by 25% of caretakers. No child wore medical identification jewelry., Conclusions: Caretakers are not always able to accurately relay vital information on their child's essential medical needs, a problem that may be compounded in emergency situations. The use of some form of independent identification and information set is needed to assure proper treatment of children with special health care needs encountering an unfamiliar health care provider.

With the methods available today, most patients who arrive at the emergency department with acute cardiogenic pulmonary edema can be treated quickly and effectively. Modern pharmacologic therapy is based on directly counteracting the physiologic abnormalities that cause pulmonary edema. Agents that are useful in reducing LV preload and afterload and in managing hypotension are nitroglycerin, ACE inhibitors, vasodilators, vasopressors, and bipyrines. Noninvasive pressure support ventilation helps patients with pulmonary edema by decreasing the work of breathing, enhancing oxygen and carbon dioxide exchange, and increasing cardiac output. Use of BiPAP systems in emergency departments has averted endotracheal intubation in about 90% of patients with pulmonary edema who are experiencing acute respiratory failure.

Introduction: Since 1987 the average length of stay for infants following hospital delivery has decreased 1.8 days. This study was undertaken to evaluate the null hypothesis that early discharge of newborns from nurseries does not result in increased emergency department (ED) utilization during the first 10 days of life. SITE: Thirty community EDs, one university ED., Methods: Retrospective review of ED visits of patients two to 10 days of age from 1989 to 1995. The absolute number of ED neonatal visits (NVs) was compared to the total number of ED visits for each year and the ratio of NV/10,000 ED visits determined. The disposition and diagnosis of each patient was noted, and the number and percent of infants admitted to the hospital calculated., Results: A total of 3.1 million ED visits were reviewed, and 2094 NVs identified. The ratio of NV/10,000 ED visits increased from 4.3 in 1989 to 7.8 in 1995 (P < 0.001), while the average length of stay for deliveries decreased from 2.79 days to 1.85 days. The mean percent of patients admitted from the ED was 10.3% and showed no statistically significant changes over the study period. The majority of visits were for minor medical or educational problems., Conclusion: The null hypothesis is rejected. Early discharge of neonates does result in increased ED utilization. No increase in admission rates for these infants was documented, indicating that patient severity did not increase with ED utilization. There is a need for improved predischarge education and greater access for episodic ambulatory complaints.

Objective: To determine whether subcutaneous lidocaine (SQL), when used to decrease the pain of IV catheter insertion, adversely affects IV access in children < 24 months of age., Methods: A historically controlled comparison of IV access successes with and without SQL in children < 2 years of age was performed in a 30,000-annual-visit community hospital ED. On-site data collected at the time of IV placement included: patient age, weight, hydration status, number of attempts, and location of attempts. All patients had IV attempts made by the same emergency physician., Results: A total of 110 children, mean age 9.6 +/- 6.9 months, were included in the study analysis. Of the 110, 70 had an IV catheter placed with no pretreatment, while 40 had SQL pretreatment. The average number of attempts for all patients was 1.36 +/- 0.73, with 83 (75%) performed successfully in 1 attempt and 101 (91%) within 2 attempts. The mean numbers of attempts were similar for the control and SQL groups: 1.34 vs 1.40, respectively (p = 0.68), as were the proportions successful in 1 attempt (77% vs 73%; p = 0.58) and within 2 attempts (91% vs 90%; p = 0.84)., Conclusion: SQL use prior to an IV attempt in children < 2 years of age does not impact vascular access. A secondary finding was that vascular access with and without SQL in infants and small children generally can be accomplished in 1 attempt.

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Objective: To describe the use of a noninvasive bi-level positive airway pressure (PAP) support system for ED patients with acute congestive heart failure (CHF)., Methods: Retrospective case series analysis of ED patients presenting with acute CHF in imminent need of endotracheal intubation (ETI) managed with a bi-level PAP system. The bi-level PAP system was applied at the discretion of the treating emergency physician. Management of the bi-level PAP system, including setting of inspiratory PAP (IPAP) and expiratory PAP (EPAP), weaning, adjunct pharmacologic therapy, and failure of bi-level PAP support, was determined by the treating physician., Results: Only two (9%) of 22 patient presentations necessitated ETI. The mean duration of bi-level PAP therapy was 7.9 hours. The mean maximum IPAP and EPAP settings were 10.8 and 5.8 cm H2O, respectively. Mean intensive care unit length of stay (LOS) was 2.4 days, with a median LOS of only 1 day. There were three deaths in the series; none were attributed to the bi-level PAP system. No technical difficulty with the bi-level PAP system was noted., Conclusion: Noninvasive pressure support ventilation with a bi-level PAP support system may avert ETI in acute CHF patients. This device can be effectively used by ED personnel.

A retrospective study of pediatric patients presenting to a community hospital emergency department with acute intentional toxidromes was conducted. The characteristics of these patients and their initial medical management were reviewed. Forty-six patients were included in this study with 35 recreational overdoses and 11 suicide attempts or gestures. The mean age of these patients was 15.8 (range 10 to 18 years). The most commonly abused substance was ethanol, followed in frequency by benzodiazepines and barbiturates. Initial management centered on active airway management, gastrointestinal decontamination, and extended observation. Ten patients were intubated, lavaged, extubated, and subsequently discharged from the emergency department. Only one patient required hospital admission. The value of toxicologic screens, emergency department endotracheal intubations, gastric lavage, and charcoal/cathartic therapy is discussed.

In an effort to assess the reliability of patient history in excluding pregnancy, we studied the correlation between specific historical factors and the presence of a positive qualitative serum beta-human chorionic gonadotropin assay. Two hundred eight patients were studied, and information was collected prospectively on a variety of historical criteria. Three historical variables were statistically less likely to be associated with pregnancy: last menstrual period that was on time, the patient thinking she was not pregnant, and the patient stating there was no chance she could be pregnant (P less than .001). There was, however, still at least a 10% chance of the patient being pregnant. Combinations of historical criteria were likewise unsuccessful at totally excluding pregnancy. These data support the contention that patient history is an unreliable method of excluding pregnancy in emergency department patients and supports the liberal use of pregnancy tests.

We report the unusual case of a compartment syndrome of the foot that developed after a calcaneal fracture in a 68-year-old man. The diagnosis was suspected clinically because of pain in excess of his injury and was confirmed with direct tissue pressure measurements. Surgical decompression of all the compartments was required with evacuation of a plantar hematoma.

Two hundred eleven consecutive admissions entered into the trauma registry of an inner-city hospital over a six-month period were studied. Length of stay, age, mechanism of injury, trauma score, gross financial charges, daily charges, and reimbursement rates were analyzed by linear multiple regression. Length of stay and gross financial charges were found to be significantly associated with age and trauma score. Daily charges were associated with length of stay and trauma score. Reimbursement rates were inversely associated with age and length of stay. The elderly make up a significant proportion of trauma victims and the cost of their care is higher than for younger patients. Because reimbursement for this age group is based largely on diagnosis-related groups, which pay only fixed costs, trauma centers must analyze the potential economic impact of older trauma victims.

Reported are two cases of stress-induced fracture of the first rib in young, healthy basketball players. Presumably the fractures resulted from violent contraction of the scalene musculature. This is the usual method of production of stress-induced first rib fracture, but basketball-related cases have not been reported previously. This entity probably is underdiagnosed, and is amenable to conservative outpatient management in most cases.

The case of a patient with apparent cocaine toxicity and drug-mediated hypertension and tachycardia is presented. IV propranolol was used as the initial treatment for his hyperadrenergic state, resulting in a decrease in heart rate but a paroxsymal increase in blood pressure. The patient required nitroprusside for control of elevated blood pressure. A mechanism of unopposed alpha stimulation as a result of beta-2 receptor blockade is proposed, and a cautious approach to the use of propranolol in these patients is suggested.

The case of a seven-month-old infant presenting in full cardiac arrest and resuscitated utilizing a right tibial intraosseous access line is presented. The child who presented in asystole appears to be the first reported case of the successful use of the intraosseous route as the sole source of drug administration. Flow time from tibia to clinical cardiac response was noted to be less than three minutes, similar to those in animal arrest models.