BACKGROUND:Syncope is a frequent reason for hospitalization from the emergency department (ED), but the benefit of hospitalization is unclear. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the potential benefit of hospitalization for ED syncope patients for developing an evidence-based ED syncope management guideline. METHODS:We conducted a SRMA according to the patient-intervention-control-outcome (PICO) framework: In patients 16 years of age or older who present to the ED with syncope (population), does hospitalization (intervention) or direct ED discharge (comparison) improve short-term outcomes (outcome)? The primary outcome was a composite of all adverse events as defined by individual studies, up to 30 days. Two reviewers independently assessed articles for inclusion and methodological quality. We measured heterogeneity among included studies with I-squared statistic and used GRADE criteria to assess the quality of evidence. RESULTS:Our search strategy identified 2140 publications and included 18 publications (510,545 participants) in the analysis. All studies reported higher rates of adverse events in hospitalized patients (0.7%-43.8%) compared to discharged patients (0%-3.7%). Our meta-analysis detected considerable statistical heterogeneity. The GRADE assessment for all adverse events and all-cause mortality revealed risk ratios of >5 favoring ED discharge for both outcomes at a median follow-up of 30 days. However, point estimates are limited by serious risk of bias, inconsistency, imprecision, indirectness, and publication bias. CONCLUSIONS:Due to the uncertainty of the available evidence, this SRMA's findings do not support a recommendation for or against hospitalizing patients presenting to ED with syncope. However, discharging low-risk patients with syncope from the ED is associated with a low risk of short-term adverse events.

BACKGROUND:Syncope places a significant burden on emergency departments (EDs), often prompting extensive testing to exclude life-threatening conditions. However, the diagnostic utility of troponin, B-type natriuretic peptide (BNP), transthoracic echocardiography (TTE), and outpatient cardiac monitoring remains unclear. METHODS:This systematic review assessed the diagnostic accuracy of these tests in adults presenting with syncope. The research question was: In ED patients with syncope, does TTE, cardiac biomarkers (troponin, BNP), or outpatient arrhythmia monitoring, compared with no testing, improve outcomes within 30 days? Primary outcomes included adverse events (death, arrhythmias, structural/ischemic heart disease, and select non-cardiac causes such as pulmonary embolism or aortic dissection) for biomarkers and diagnostic yield for TTE and monitoring. Sensitivity, specificity, and likelihood ratios (LR+ and LR-) were calculated for biomarkers, while diagnostic yield with 95% CI was reported for TTE and monitoring. Risk of bias was assessed using JBI and QUADAS-2. RESULTS:The database searches identified 1759 citations. After applying inclusion and exclusion criteria, 41 studies (21,557 patients) were included. Significant heterogeneity among the included trials (all with I2 > 90%) precluded meta-analysis. For BNP, LR+ ranged 1.4-47 and LR- 0.06-0.4; for troponin, LR+ 1.9-11.2 and LR- 0.2-0.9. TTE diagnostic yield was 0%-29% overall and 8%-28% in high-risk groups. Outpatient monitoring yielded 1%-59% overall and 12%-42% in high-risk patients. CONCLUSION:In ED patients with syncope, the diagnostic accuracy and yield of cardiac biomarkers, TTE, and outpatient monitoring show substantial variability, largely due to differences in patient populations, outcome measures, and study methodologies. Based on the existing evidence, these modalities in isolation cannot be recommended for routine use in syncope evaluation. Among these tests, the diagnostic yield of TTE and outpatient monitoring is greater in patients with cardiac risk factors and could potentially contribute to a more accurate diagnosis.

BackgroundMost victims of trauma and abuse will seek care in an emergency department (ED) within hours of their violence-related injuries. Medical training has produced well-trained physicians to evaluate, stabilize, and treat these patients in the acute setting. Unfortunately, in an ED without forensic staff, lack of timely forensic care can result in delays in treatment, loss of evidence, and hope of any justice being achieved. Emergency physicians are in a unique position to provide critical medical and forensic care to these patients, especially in health care facilities without 24-h coverage of forensic staff and social workers.MethodsIn 2022, Kings County Hospital developed a clinical forensics medicine fellowship to provide specialized care to victims of trauma and provide additional training to emergency medicine (EM) residents. A clinical forensic medicine (CFM) curriculum was created to introduce trauma-informed care in adult and pediatric EM training programs. It demonstrated how forensic medicine can play an integral role in the road to recovery for victims, without interfering with the delivery of critical medical care.ResultsThis article describes the development of a clinical forensics medicine fellowship at Kings County Hospital using Kern's six-step approach to curriculum design. It includes the problem identification, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation.ConclusionsThis article elaborates on the importance of CFM in EM residency training and provides the framework to replicate the fellowship at any institution.

Background Child maltreatment is a significant public health problem. Emergency departments are often the first contact points for suspected child maltreatment. Variability in the decision of whether or not to report maltreatment cases to Child Protective Services (CPS) may lead to missed opportunities for diagnosis and intervention or unnecessary medical and social interventions. Objective To evaluate the variability in choosing to report child maltreatment cases among emergency department physicians. Participants and Setting: Our survey was conducted on Emergency physicians through the PED-EM-L@LISTSERV.BROWN.EDU listserv Methods We queried emergency physicians with a 19-question survey. Seven clinical scenarios were designed by our Pediatric Emergency division in consultation with a child abuse specialist. Scenarios were created with varying degrees of suspicion for child maltreatment. Our survey asked physicians if they would report each case to CPS. We collected demographic information regarding the physician, their work setting, and their patient population. The responses for individual scenarios were analyzed as percentages and compared with demographic data by Fisher’s exact test. Our survey received 307 responses. Results Most of our 307 respondents are specialized in pediatric emergency medicine (95.6%). Of the seven scenarios, physicians near-unanimously (99.3%, 95% CI 97.9-99.9%) agreed in only one scenario. For the other six scenarios, agreement ranged from 54.4% (95%CI: 48.8-59.9%) to 80.1% (95%CI: 75.4-84.3%). Demographics, including physician age, gender, ethnicity, years of experience, population ethnicity, and hospital location, did not explain variability in choosing to report to CPS. Conclusion Our study shows significant variability in reporting child maltreatment cases, not explained by hospital or physician demographics

OBJECTIVES:Approximately 10% of patients with syncope have serious or life-threatening causes that may not be apparent during the initial emergency department (ED) assessment. Consequently, researchers have developed clinical decision rules (CDRs) to predict adverse outcomes and risk stratify ED syncope patients. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the methodological quality and predictive accuracy of CDRs for developing an evidence-based ED syncope management guideline. METHODS:We conducted a systematic literature search according to the patient-intervention-control-outcome question: In patients 16 years of age or older who present to the ED with syncope for whom no underlying serious/life-threatening condition was found during the index ED visit (population), are risk stratification tools (intervention), better than unstructured clinical judgment (i.e., usual care; comparison), for providing accurate prognosis and aiding disposition decision for outcomes within 30 days (outcome)? Two reviewers independently assessed articles for inclusion and methodological quality. We performed statistical analysis using Meta-DiSc. We used GRADEPro GDT software to determine the certainty of the evidence and create a summary of the findings (SoF) tables. RESULTS:Of 2047 publications obtained through the search strategy, 31 comprising 13 CDRs met the inclusion criteria. There were 13 derivation studies (17,578 participants) and 24 validation studies (14,845 participants). Only three CDRs were validated in more than two studies. The San Francisco Syncope Rule (SFSR) was validated in 12 studies: positive likelihood ratio (LR+) 1.15-4.70 and negative likelihood ratio (LR-) 0.03-0.64. The Canadian Syncope Risk Score (CSRS) was validated in five studies: LR+ 1.15-2.58 and LR- 0.05-0.50. The Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score was validated in five studies: LR+ 1.16-3.32 and LR- 0.14-0.46. CONCLUSIONS:Most CDRs for ED adult syncope management have low-quality evidence for routine clinical practice use. Only three CDRs (SFSR, CSRS, OESIL) are validated by more than two studies, with significant overlap in operating characteristics.

Background: Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. Objective: Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. Methods: Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age <= 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. Results: Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age <= 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). Conclusion: Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study. Published by Elsevier Inc.

Background and aim: Describe the prevalence/outcomes of Diabetic Ketoacidosis (DKA) patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods. Methods: Retrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients that takes place in Eleven hospitals of New York City Health & Hospitals. Our included participants during the pandemic period were admitted COVID-19+ patients (>18 years) and during the pre-pandemic period were admissions (>18 years) selected through the medical record. We excluded transfers during both periods. The intervention was COVID-19+ by PCR testing. The main outcome measured was mortality during the index hospitalization and secondary outcomes were demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (>0.4 mmol/L) and bicarbonate (<15 mmol/L) or pH (<7.3). Results: Demographics and past medical histories were similar during the pre-pandemic (n = 6938) vs. pandemic (n = 7962) periods. DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period ( 0.72%, 0.54-0.95) (p > 0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p < 0.001). Surviving vs. non-surviving DKA/COVID-19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0-4.5) (p < 0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2-3.1) (p < 0.001). Conclusions: COVID-19 increased the prevalence of DKA with higher mortality rates secondary to COVID-19 severity, not DKA. We suggest DKA screening all COVID-19+ patients and prioritizing ICU DKA/COVID-19+ with low oxygen saturation, blood pressures, or renal insufficiency. (c) 2022 Diabetes India. Published by Elsevier Ltd. All rights reserved.

BackgroundDiabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA.Study ObjectiveDescribe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods.Methods:DesignRetrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student's t-tests or Fisher's Exact Test, where appropriate, and odds ratios to predict mortality.ResultsDemographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015).DiscussionWe found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity.ConclusionWe found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)No, authors do not have interests to disclose BackgroundDiabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA. Diabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA. Study ObjectiveDescribe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods.Methods: Describe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods. Methods: DesignRetrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student's t-tests or Fisher's Exact Test, where appropriate, and odds ratios to predict mortality. Retrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student's t-tests or Fisher's Exact Test, where appropriate, and odds ratios to predict mortality. ResultsDemographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015). Demographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015). DiscussionWe found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity. We found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity. ConclusionWe found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.View Large Image Figure ViewerDownload Hi-res image Download (PPT)No, authors do not have interests to disclose We found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.

Objectives Many adolescents use the emergency department as their sole resource for primary care and sexual health care. This provides an opportunity to prevent sexually transmitted infections and unintended pregnancy as well as to educate teenagers about their bodies and sexual health. There is no standard curriculum on sexual health as part of pediatric emergency medicine (PEM) fellowship education. Our goal is to evaluate what is taught in PEM fellowship about adolescent sexual health. Methods We administered an anonymous questionnaire to both PEM fellows and program directors (PDs). The questionnaire was distributed through the PEM Program Director Survey Committee. The questionnaire was sent to 88 PDs and 305 fellows total. An introductory email explaining the purpose of the study and a link to the online questionnaire was sent. The questionnaire was created using SurveyMonkey (www.surveymonkey.com). Data were analyzed using descriptive statistics. Results We achieved a 43% survey response rate from PDs (38 of 88) and a 24% survey response rate from fellows (73 of 305). The PD respondents included 61% females, and almost all (86%) are between ages 35 and 54 years. Seventy-three percent of the fellows are female, and they are all between 25 to 44 years old. There was a great deal of variability in the amount of adolescent sexual health education PDs provide their fellows in the form of lectures and bedside teaching cases. A majority of survey respondents (86% of fellows and 66% of the PDs) agreed that there should be a standard PEM curriculum to teach about adolescent sexual health. More than half (53% of PDs and 56% of fellows) are not satisfied with the number of training opportunities for adolescent sexual health. Conclusions We found variability in adolescent sexual health training during PEM fellowship, although fellows and PDs agree that there should be a standardized curriculum. We recommend that the American Board of Pediatrics form a committee to decrease variability in the training of PEM fellows on adolescent sexual health.

This is a peer review report related to MS ID#29539

Introduction: Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE. Study Objective: The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE. Methods: This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed. Results: All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s). Conclusion: There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Osteomyelitis is inflammation of bones almost exclusively in the metaphysis, most commonly in the femur and tibia.1 Infection of the clavicle is rare, occurring in 1% to 3% of pediatric cases.2 Nonpenetrating traumas precede these cases, and the resulting local bone injury is the catalyst for infection.1 In addition to being a rare condition, osteomyelitis of the clavicle is also difficult to diagnose, often mistaken for more common illnesses. This case report highlights these challenges.

Background: Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures. Objectives: We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients. Methods: We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc. Results: Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of similar to 2% would require a negative skull ultrasound in a patient with only a pretest probability of similar to 15%. Conclusions: A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.

Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA’s ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs?

COVID-19, an illness caused by the novel coronavirus SARS-CoV-2, affected many aspects of healthcare worldwide in 2020. From March to May of 2020, New York City (NYC) experienced a large surge of cases. The authors aimed to characterize the amount of illness experienced by residents and fellows in 2 NYC hospitals during this time period. This was a cross-sectional observational study. An IRB-exempt survey was distributed to emergency medicine housestaff in May 2020 and submissions were accepted through August 2020. 64 residents and fellows responded to our survey (a 62% response rate). 42% of responders tested positive for SARS-CoV-2 antibodies. Most residents experienced symptoms that could be consistent with COVID-19 however few received PCR testing. Fevers and/or chills along with loss of smell and/or taste were the most specific symptoms for COVID-19, with p-values <0.05. All 13 housestaff who reported no symptoms during the study period tested negative for SARS-CoV-2 antibodies. Our study demonstrated that the rate of COVID-19 illness among emergency department housestaff is much higher than previously reported. Further studies are needed to characterize illness among medical staff in emergency departments across the nation. The high infection rate among emergency medicine trainees stresses the importance of supplying adequate PPE for healthcare professionals.

Background Iatrogenic pulmonary air embolism is a fairly common and sometimes deadly complication of i.v. contrast injection. Case Report We present the case of a 33-year-old man with a symptomatic iatrogenic injection air embolism and resolution within 5 h. Why Should an Emergency Physician Be Aware of This? Given the importance of computed tomography imaging in emergency medicine, clinicians should be aware of the risk for injection air embolism from i.v. contrast injection.

Context: Febrile neutropenic immunocompromised children are at a high risk of Serious Bacterial Infections (SBI). Objective: This systematic review and meta-analysis report the prevalence of SBI in healthy children with febrile neutropenia. Data source: PubMed, EMBASE, and Web of Science from their inception to August 2020. Study selection: Patients with an Absolute Neutrophil Count (ANC) <1000 cells/mm(3) up to 18 years of age presenting to the ED with a chief complaint of fever (temperature > 38 degrees C) and who had a workup for SBI as defined by each study. Data abstraction: Data from individual studies was abstracted by a subset of the authors and checked independently by the senior author. Any discrepancies were adjudicated by the joint agreement of all the authors. We calculated the prevalence of SBI by using the number of SBI's as the numerator and the total number of febrile events in patients as the denominator. Bias in our studies was quantified by the Newcastle Ottawa Scale. Results: We identified 2066 citations of which five studies (1693 patients) our inclusion criteria. None of our reviewed studies consistently tested every included patient for SBI. Spectrum bias in every study resulted in a wide range of the SBI prevalence of 1.9% (<0.01% - 11%) similar to non-neutropenic children. Limitations: All of our studies were retrospective and many did not consistently screen all subjects for SBI. Conclusion: If the clinical suspicion is low, the risk for SBI is similar between febrile healthy neutropenic and non-neutropenic children. (C) 2021 Elsevier Inc. All rights reserved.

Objective Pneumococcal vaccination has decreased the bacteremia rate in both the general pediatric and sickle cell disease (SCD) populations. Despite this decrease, and an increasing concern for antibiotic resistance, it remains standard practice to obtain blood cultures and administer antibiotics in all febrile (>38.5 degrees C) patients with SCD. We conducted a systematic review and meta-analysis of the available studies of the prevalence of bacteremia in febrile patients with SCD. Methods We searched the medical literature up to November 2018 in PUBMED, EMBASE, and Web of Science with terms epidemiology, prevalence, bacteremia, and sickle cell anemia. We only included studies with patients after 2000, when the pneumococcal 7-valent conjugate (PCV7) vaccine became widely available. The prevalence of bacteremia [95% confidence interval (CI)] was calculated by dividing the number of positive blood cultures by the number of febrile episodes. The I-2 statistic measured heterogeneity between prevalence estimates. Bias in our studies was quantified by the Newcastle-Ottawa Quality Assessment Scale. Results Our search identified 228 citations with 10 studies meeting our inclusion/exclusion criteria. The weighted prevalence of bacteremia across all studies was 1.9% (95% CI, 1.22%-2.73%), and for Streptococcus pneumoniae bacteremia, it was 0.31% (95% CI, 0.16%-0.50%). Risks for bacteremia except central lines could not be determined because of the low prevalence of the outcome. Conclusions There appears to be a need to develop a risk stratification strategy to guide physicians to manage febrile patients with SCD based on factors including, but not limited to, history and clinical examination, vaccination status, use of prophylactic antibiotics, laboratory values, likely source of infection, and accessibility to health care.