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Background: Pain can impair functional status, including a patient's ability to return to work. The purpose of this study was to determine whether there was an association between pain levels and return-to-work status during the first 4 days post-ED discharge in ED patients seen for undifferentiated acute pain., Methods: This secondary analysis of data from the Acute Management of Pain from the Emergency Department (AMPED) registry included patients who reported working either full-time or part-time. We used Cox regression models to examine the association between daily self-reported minimum and maximum pain scores and first return to work. We used repeated measures logistic regression models to examine the association between daily minimum and maximum pain scores and daily return-to-work status., Results: Of the 610 employed patients, 481 (78.9%) were employed full-time and 129 (21.1%) part-time. The average delay in returning to work after ED visit was 2.4 days. For all models, higher minimum and maximum daily pain scores predicted lower daily return-to-work rates in the first four days post-ED discharge. The adjusted hazards ratios for first return to work were 0.91 (0.87, 0.96) and 0.93 (0.89, 0.97), while the adjusted odds ratios for daily return-to-work status were 0.80 (0.75, 0.85) and 0.88 (0.83, 0.93) for every one-point increase in minimum and maximum pain scores, respectively., Conclusion: Higher daily pain severity is associated with decreased return-to-work after ED visits for acute pain, highlighting the importance of adequate discharge pain management from the ED., Competing Interests: Declaration of Competing Interest The authors acknowledge funding for the parent study (AMPED) from Luitpold Pharmaceuticals (United States of America). This research has been presented at the Society of Academic Emergency Medicine National conference in May 2019., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The Safety of Oral Anticoagulants Registry (SOAR) was designed to describe the evaluation and management of patients with oral anticoagulant (OAC)-related major bleeding or bleeding concerns who present to the emergency department (ED) with acute illness or injury. Patients in the ED are increasingly taking anticoagulants, which can cause bleeding-related complications as well as impact the acute management of related or unrelated clinical issues that prompt presentation. Modifications of emergency evaluation and management due to anticoagulation have not previously been studied., Methods: This was a multicenter observational in-hospital study of patients who were judged to be experiencing an active OAC effect and had (a) an obvious bleeding event or (b) were deemed at risk for serious bleeding spontaneously, after injury, or during an indicated invasive procedure. Diagnostic testing, therapies employed, and clinical outcomes were collected., Results: Thirty-one US hospitals contributed data to SOAR. Of 1513 subjects, acute hemorrhage (AH) qualified 78%, while 22% had a bleeding concern (BC). Warfarin was the index OAC in 37.3%, dabigatran in 13.3%, and an anti-Factor X a in 49.4%. The most common sites of AH were gastrointestinal (51.0%) and intracranial (26.8%). In warfarin-treated patients, the mean (IQR) presenting INR was 3.1 (2.2, 4.8) in AH patients and 3.9 (2.4, 7.2) in BC patients. Three-fifths of SOAR patients were treated with factor repletion or specific reversal agents, and those patients had a longer length of stay. In addition, seven (0.76%) of the treated patients experienced an in-hospital thrombotic complication; two of these seven died on the index admission, both of fatal pulmonary embolism. Vitamin K was used and dosed inconsistently in both warfarin and NOAC cohorts., Conclusion: Care of anticoagulated patients in the acute care setting is inconsistent, reflecting the diversity of presentation. As the prevalence of OAC use increases with the aging of the US population, further study and targeted educational efforts are needed to drive more evidence-based care of these patients., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Idarucizumab is a monoclonal antibody fragment specifically targeted to dabigatran. It has demonstrated prompt and durable reversal of the anticoagulant effects of dabigatran in animal studies and phase 1 studies of young, elderly, and renally impaired volunteers. Although elective invasive procedures and most bleeding complications in dabigatran-treated patients can be managed by temporarily stopping dabigatran therapy and using supportive measures, there are rare clinical situations that require urgent reversal of the anticoagulant effect of dabigatran. The effectiveness and safety of 5 g of intravenous idarucizumab is being investigated in a prospective, open-label, single-cohort study in patients with serious bleeding or in those requiring an urgent procedure. In an interim analysis of the first 90 participants, idarucizumab rapidly and completely reversed the anticoagulant activity of dabigatran in 88%-98% of participants, and there were no safety concerns, with no deaths or serious adverse events being attributable to idarucizumab. Supported by these interim results, idarucizumab has been approved in the United States and the European Union for use when reversal of the anticoagulant effects of dabigatran is needed for emergency surgery/urgent procedures or in patients with life-threatening or uncontrolled bleeding. Clinical use of idarucizumab should follow the same processes as patient enrollment in this study, which is projected to be completed in 2016. The outcomes achieved with this specific reversal agent are likely to be of continued interest to treating physicians., (Copyright © 2016. Published by Elsevier Inc.)

Venous thromboembolism (VTE) is a disease spectrum that ranges from deep vein thrombosis (DVT) to pulmonary embolism (PE). Rapid diagnosis and treatment of VTE by emergency care providers are critical for decreasing patient mortality, morbidity, and the incidence of recurrent events. Recent American College of Chest Physicians guidelines recommend initial treatment with unfractionated heparin, low-molecular weight heparin, or fondaparinux overlapped with warfarin for a minimum of 5 days for the treatment of VTE in most cases. Warfarin monotherapy is thereafter continued for 3, 6, or 12 months. These guidelines were published before the approval of target-specific oral anticoagulants (TSOACs), and they have yet to be updated to reflect these new treatment options. For some patients, TSOACs, which act by directly inhibiting factor IIa or factor Xa, may provide safer, more convenient alternatives to warfarin. Their advantages include ease of use, reduced monitoring requirements, and lower bleeding risk than traditional therapy. Additionally, clinical trials have established noninferiority of TSOACs to warfarin for the prevention of recurrent VTE. These trials have demonstrated that TSOACs exhibit similar or lower bleeding rates, particularly intracranial bleeding rates compared with warfarin. Anticoagulation therapy with TSOACs may allow early discharge or outpatient management options for low-risk patients with DVT and PE. This review addresses the importance of early diagnosis and treatment of VTE, outcomes of VTE risk assessment, key efficacy and safety data from phase 3 clinical trials for the various TSOACs for the treatment of DVT and PE, and the corresponding considerations for clinical practice., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Study Aim: Clinical guidelines recommend fibrinolysis or embolectomy for acute massive pulmonary embolism (PE) (MPE). However, actual therapy and outcomes of emergency department (ED) patients with MPE have not previously been reported. We characterize the current management of ED patients with MPE in a US registry., Methods: A prospective, observational, multicenter registry of ED patients with confirmed PE was conducted from 2006 to 2008. Massive PE was defined as PE with an initial systolic blood pressure less than 90 mm Hg. We compared inpatient and 30-day mortality, bleeding complications, and recurrent venous thromboembolism., Results: Of 1875 patients enrolled, 58 (3.1%) had MPE. There was no difference in frequency of parenteral anticoagulation (98.3% [95% confidence interval {CI}, 90.5-101.6] vs 98.5% [95% CI, 97.9-99.1], P = .902) between patients with and without MPE. Fibrinolytic therapy and embolectomy were infrequently used but were used more in patients with MPE than in patients without MPE (12.1% [95% CI, 3.7-20.5] vs 2.4% [95% CI, 1.7-3.1], P < .001, and 3.4% [95% CI, 0.0-8.1] vs 0.7% [95% CI, 0.3-1.1], P = .022, respectively). Comparison of outcomes revealed higher all-cause inpatient mortality (13.8% [95% CI, 4.9-22.7] vs 3.0% [95% CI, 2.2-3.8], P < .001), higher risk of inpatient bleeding complications (10.3% [95% CI, 2.5-18.1] vs 3.5% [95% CI, 2.7-4.3], P = .007), and a higher 30-day mortality (14.0% [95% CI, 4.4-23.6] vs 1.8% [95% CI, 1.2-2.4], P < .001) for patients with MPE., Conclusions: In a contemporary registry of ED patients, MPE mortality was 4-fold higher than patients without MPE, yet only 12% of the MPE cohort received fibrinolytic therapy. Variability exists between the treatment of MPE and current recommendations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Emergency department (ED) clinicians are not typically involved in the long-term management of patients' anticoagulation therapy, but they are responsible for decision making for emergency conditions requiring anticoagulation, such as acute venous thromboembolism (VTE). In addition, emergency physicians are often faced with patients who present first to the ED with conditions that may prompt long-term anticoagulation upon hospital discharge, such as atrial fibrillation (AF), or who have acute or potential bleeding complications from anticoagulation., Objective: In this review, clinical trials of new oral anticoagulants evaluated for treatment of VTE and stroke prophylaxis in AF, as well as practical management aspects, will be discussed. In addition, clinical trials evaluating the adjunctive use of the new oral anticoagulants with antiplatelet therapy in patients who have experienced acute coronary syndrome will be explored., Discussion: Both dabigatran etexilate and rivaroxaban have successfully completed phase III trials for acute VTE treatment and are currently approved for the reduction of risk of stroke and systemic embolism in patients with nonvalvular AF. In a recently completed phase III trial, apixaban also demonstrated promising efficacy and safety in that indication. Rivaroxaban represents the only new anticoagulant to date to have shown promising phase III results as an adjunct to antiplatelet therapy after acute coronary syndrome., Conclusion: Knowledge of the appropriate clinical use and safety concerns of the new anticoagulants is imperative as they become more frequently prescribed, and their potential uses in the ED setting represent an important aspect of continuing education for emergency physicians., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Clinical trials are the foundation underlying clinical decision-making. However, stringent inclusion and exclusion criteria may reduce the generalizability of their results, especially for patients seen in the emergency department (ED). Guideline recommendations, based on clinical trials and pertinent registries, apply to broad populations, but not all patients cared for at the bedside fit the predefined categories that make guidelines practical. Furthermore, these documents may not incorporate the latest evidence. As a result, other factors (eg, individual patient characteristics, clinician experience, cost, regulatory labels, expert opinions) often result in clinical decision-making that varies from strict adherence to guideline recommendations., Objectives: These challenges demonstrate a need to integrate clinical data and guidelines advice with actual ED practice in a manner that will be consistent with decisions made later in the continuum of care., Discussion: In recognition of these issues, a roundtable was convened in New York City on June 5, 2009, to discuss the implications of recent trials involving patients with non-ST-segment elevation acute coronary syndromes. Eight physicians, representing both emergency medicine and cardiology, shared information on advances and clinical trial results in antiplatelet treatment, guidelines, and other developments in patient care. This article is based on transcripts of their presentations and the ensuing discussions that were of particular importance for emergency physicians., Conclusions: Although guidelines and clinical registries can provide broad direction for practice, there is no substitute for a prospective, multidisciplinary, institution-specific, consistent, evidence-based approach to patient management., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Acute heart failure (AHF) is a common, poorly characterized manifestation of hypertensive emergency. We sought to describe characteristics, treatment, and outcomes of patients with severe hypertension complicated by AHF., Methods and Results: The observational retrospective Studying the Treatment of Acute hypertension (STAT) registry records data on emergency department and hospitalized patients receiving intravenous therapy for blood pressure (BP) greater than 180/110 mm Hg in 25 US hospitals. A subset of patients with HF was defined as pulmonary edema on chest x-ray (CXR) or an elevated B-type natriuretic peptide level (BNP > 500 or NTproBNP > 900 pg/mL) in patients with creatinine level 2.5 mg/dL or less. Remaining STAT patients, after excluding those with a primary neurologic diagnosis, constitute the non-HF cohort. An adverse composite outcome was defined as mechanical ventilation, intensive care unit (ICU) admission, hospital length of stay more than 1 week, or death within 30 days. Of 1199 patients, 302 (25.2%) had AHF. Acute HF patients and non-AHF patients were similar in age, sex, and overall mortality, but AHF patients were more commonly African American, with a history of HF, diabetes or chronic obstructive pulmonary disease, and prior hypertension admissions. Heart failure patients had higher creatinine and natriuretic peptide levels but lower ejection fraction. They were more likely admitted to the ICU; receive electrocardiograms, bilevel positive airway pressure ventilation, and CXRs; and be readmitted within 90 days. Finally, BP decreases lower than 120 mm Hg within 12 hours were associated with an increased rate of the composite adverse outcome., Conclusions: Acute HF as a manifestation of hypertensive emergency is common, more likely in African Americans, and requires more clinical resources than patients with non-HF-related severe hypertension. Accurate BP control is critical, as declines less than 120 mm Hg were associated with increased adverse event rates., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS)., Materials and Methods: This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk. Patients were included in this registry if they were at least 18 years old and had suspected ACS at the time of their ED visit. Inclusions in this analysis required that patients had at least 1 cardiac marker (creatine kinase-MB [CK-MB], troponin T, or troponin I) drawn twice within 6 hours of presentation, with both measures being below the institution's upper limit of normal. A marker change was defined as either an increase or decrease that exceeded 15% of the institutional upper limit of normal. Acute coronary syndrome was defined as a positive stress test, documented myocardial infarction, coronary revascularization, or death within 30 days of their ED admission., Results: Of 17,713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS., Conclusions: Small increases in troponin concentration below the upper limit of normal are associated with increased odds of ACS., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The crucial aim in the emergency management of patients presenting with chest pain is the identification of acute coronary syndromes (ACS) and the initiation of appropriate treatment. Institution-specific triage to initial medical or interventional therapies is influenced by the availability of percutaneous coronary intervention (PCI) facilities. Although the use of invasive strategies has increased, most US hospitals do not have PCI facilities. Pharmacological management is an integral part of all treatment strategies, regardless of the availability of interventional capability. Given the growing importance of invasive management strategies, a therapy that is compatible with both medical and invasive therapy options is becoming increasingly important. Aspirin and clopidogrel are recommended for patients with ACS regardless of the conservative or invasive management strategy. With enoxaparin, patients with ACS can seamlessly transition from the medical management phase to the interventional management phase without the need for introducing a second anticoagulant in the cardiac catheterization laboratory. Fondaparinux can be used for patients with ACS treated medically, but should not be used alone during PCI because of the risk of catheter thrombosis. Bivalirudin can be used in non-ST-segment elevation myocardial infarction patients who are managed invasively.

Current treatment guidelines recommend an early, aggressive strategy in patients with non-ST-elevation acute coronary syndromes. Administration of antiplatelet therapy--a glycoprotein IIb-IIIa inhibitor with or without clopidogrel--before catheterization in patients with high-risk features confers substantially reduced risk of ischemic events while potentially increasing bleeding risk. Strategies for risk stratification are therefore important in the emergency department, with appropriate pharmacotherapy. This review will examine implications of the new guidelines for management of patients with unstable angina/non-ST-elevation myocardial infarction for emergency physicians, review current risk stratification paradigms, and evaluate appropriate use and timing of administration of glycoprotein IIb-IIIa inhibitors and clopidogrel for patients at varying levels of risk. We will also examine mechanisms for generating institutional care pathways that can enhance consistency and quality of care as well as communication among members of the medical team responsible for caring the patient with acute coronary syndrome.

Objective: To describe time to electrocardiogram (ECG) acquisition, identify factors associated with timely acquisition, and evaluate the influence of time to ECG on adverse clinical outcomes., Methods: We measured the door-to-ECG time for emergency department patients enrolled in prospective chest pain registry. Clinical outcomes were defined as occurrence of myocardial infarction or death within 30 days of the visit., Results: Among patients with acute coronary syndrome (ACS), 34% and 40.9% of patients with non-ST-elevation ACS and ST-elevation myocardial infarction (STEMI), respectively, had an ECG performed within 10 minutes of arrival. A delay in ECG acquisition was only associated with an increase risk of clinical outcomes in patients with STEMI at 30 days (odds ratio, 3.95; 95% confidence interval, 1.06-14.72; P = .04)., Conclusion: Approximately one third of patients with ACS received an ECG within 10 minutes. A prolonged door-to-ECG time was associated with an increased risk of clinical outcomes only in patients with STEMI.

Acute ST-segment elevation myocardial infarction continues to be associated with substantial mortality rates. Despite much advancement in care, current treatments have also failed to eliminate the significant risk of morbidity, including reinfarction, reocclusion of the infarct-related artery, and thromboembolic stroke. The potential benefit of early thrombolytic therapy in reducing mortality was first established in 1986. Further benefits of conjunctive therapy with aspirin were demonstrated soon thereafter. This review examines the most significant trends in the pharmacologic therapy of ST-segment elevation myocardial infarction since the publication of these early studies: the development of fibrinolytic drugs with improved clot selectivity and improved pharmacokinetic profiles that simplify administration, making ED or even prehospital thrombolysis more practical. More recent data can be interpreted as showing that regimens that are simpler and easier to administer are also clinically superior. This article reviews pharmacologic advances and evaluates the evidence for their use in EDs.

The weanling pig model was used to determine the long-term local effects, if any, on tibial bone marrow after intraosseous (IO) infusion of resuscitation fluid and drugs at standard dosages. One of six IO treatments (two normal saline boluses [20 mL/kg]; bolus sodium bicarbonate [1 mEq/kg]; 10% sodium bicarbonate infusion at a maintenance rate for 1 hour; bolus 1:10,000 epinephrine [0.01 mg/kg]; 1:10,000 epinephrine solution infusion, 1 microgram/kg/min for 1 hour; or dopamine infusion, 10 micrograms/kg/min for 1 hour) was randomly administered via the left tibia to 18 pigs at 4 weeks of age. The animals were subsequently followed for 3 months, after which marrow from the same space and peripheral blood were examined. Marrow from the right tibia of each animal served as control; untreated historic controls were also used for comparison. Examination of the marrow revealed normal cell differentials in all limbs in all groups. Overall cellularity was somewhat decreased in the experimental limbs of the normal saline bolus group when compared with same-animal control limbs, perhaps due to the pressure effect from rapid injection. Peripheral blood counts and differentials in these and all other animals were normal. The authors conclude that IO administration of commonly used resuscitative medications does not result in significant adverse effects in the tibial bone marrow in this model.