Background: Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. Case Report: A 78 -year -old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum beta -lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point -of -care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter -directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Why Should an Emergency Physician Be Aware of This?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, pointof -care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence -based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs. (c) 2024 Elsevier Inc. All rights reserved.

Introduction: The costoclavicular brachial plexus block (CCBPB) has emerged as a more effective approach to regional anesthesia of the upper extremity. The costoclavicular space is the anterior portion of the superior thoracic aperture, located between the clavicle and first rib. The brachial plexus cords traverse this space clustered together in a superficial location lateral to the axillary artery and share a consistent topographical relationship to one another. By targeting the brachial plexus at this specific anatomical location, the CCBPB offers a powerful, single-shot, sensorimotor block of the upper extremity below the shoulder. We present a novel application of the CCBPB to facilitate emergency department (ED) analgesia and closed reduction of an upper extremity fracture.Case Report: A 25-year-old male presented to the ED with a traumatic Colles fracture sustained during a high-speed motor vehicle collision. Despite multimodal analgesia, the patient reported intractable severe pain with intolerance of radial manipulation. An ultrasound-guided CCBPB was performed to augment pain control and avoid procedural sedation, resulting in dense, surgical anesthesia of the upper extremity, and painless fracture reduction.Conclusion: Regional anesthesia is an effective component of multimodal pain management and another tool in the emergency physician’s analgesic armamentarium. In acute orthopedic traumas necessitating emergent reduction, regional blocks serve as rescue pain control and can obviate the need for procedural sedation. In terms of targeted upper extremity analgesia, the CCBPB offers effective, single-shot, sensorimotor blockade below the shoulder, mitigating use of opioids and their deleterious side effects, while simultaneously avoiding incomplete blockade or phrenic nerve palsy associated with other approaches to brachial plexus blockade.

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a reversible condition with nonspecific neurologic and characteristic radiologic findings. Clinical presentation may include headache, nausea, vomiting, altered mental status, seizures, and vision changes. Diagnosis is confirmed through T2-weighted brain magnetic resonance imaging (MRI) showing bilateral hyperintensities in the white matter of posterior circulatory regions. Case Report: We report a case of PRES in a patient suffering from complicated diverticulitis. Following medical management in the emergency department, the patient deteriorated, becoming hypotensive and altered. Bowel resection under general anesthesia was performed. Postoperative brain MRI demonstrated bilateral and symmetric T2 signal hyperintensities suggestive of PRES. Following supportive treatment, the patient was discharged from the surgical intensive care unit on postoperative day 21 with no residual deficits.Conclusion: It is important to recognize the nonspecific neurologic symptoms associated with PRES. Emergency physicians should suspect acute PRES when managing patients with prolonged or unexplained encephalopathy, while recognizing that hypertension need not be present.

Background: Public reporting of the Centers for Medicare 8c Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance.Methods: Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis -related QI activities for comparison based on SEP-1 performance.Results: Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores ( r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores.Conclusion: Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.

A significant number of ED programs do not have a standardized sign-out process. Implementation of a standardized sign-out protocol in the ED was shown to lead to a decreased length of stay and increased frequency of ED bedside rounding. The question that has yet to be asked is: how does residency training affect one's perception of sign-out on safety and efficiency? Investigators surveyed attending physicians and residents of five EM programs via email and paper surveys. 85 survey samples were completed, with 31 PGY-1s, 16 PGY-2s, 19 PGY-3s, and 18 attending physicians. Descriptive statistics and t-test for comparison of items on a Likert scale were obtained. The measured outcome is the participants' perception of the relative importance of sign-out as a contributor to patient safety and care efficiency. 30% of respondents (38%, 38%, 21%, 22% PGY-1, 2, 3 and attending) never received any training on proper sign-out. 13% considered sign-out as having "little effect" or "no effect" on patient safety and care efficiency. 74% thought sign-out affected safety "a great deal" or "a lot," with 53% similar answers on care efficiency. PGY-1 residents' perception on the relative importance of sign-out on care efficiency is lower than that of attending physicians' (p<0.05), but this difference disappears between groups (ANOVA, p>0.05). There is no statistical difference between groups (p>0.05) in the perception of the relative importance of sign-out on patient safety. The results of this survey suggest that training enhances residents' perception of the effect of sign-out on patient care efficiency and efficiency. Current research points out that standardized sign-out in the ED can result in lower LOS and reduce rate of adverse events. It suggests that greater efforts should be emphasized on sign-out education in the emergency department and the implementation a standardized sign-out protocol.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Therapeutic hypothermia, the standard for post-resuscitation care of out-of-hospital sudden cardiac arrest (SCA), is an area that the most recent resuscitation guidelines note "has not been studied adequately." We conducted a two-phase study examining the role of intra-arrest hypothermia for out-of-hospital SCA, first standardizing the resuscitation and transport of patients to resuscitation centers where post-resuscitation hypothermia was required and then initiating hypothermia during out-of-hospital resuscitation efforts. The primary end points were return of spontaneous circulation (ROSC), sustained ROSC, survival to hospital admission, and survival to discharge. Comparing the cohort of standard hospital-initiated hypothermia (Phase I) with the prehospital-initiated hypothermia via large-volume ice-cold saline (LVICS) infusion (Phase II), no difference was noted for any end point: ROSC (56.4% vs. 53.4%, p = 0.51; 95% confidence interval [CI]: -5.7 to 11.4), sustained ROSC (46.9% vs. 42.8%, p = 0.38; 95% CI: -4.7 to 12.4), hospital admission (44.7% vs. 37.7%, p = 0.13; 95% CI: -1.9 to 15.4), hospital discharge among those surviving to admission (40.0% vs. 28.0%, p = 0.08; 95% CI: -1.5 to 27.8), or neurological outcome among those surviving to discharge (76.0% vs. 71.4%, p = 0.73; 95% CI: -26.9 to 38.7). Patients presenting in ventricular fibrillation were more likely to survive to hospital discharge in both phases, although a trend toward worsened early outcomes (ROSC, sustained ROSC, and survival to admission) with intra-arrest hypothermia was noted in this subgroup. Multivariable regression analyses failed to demonstrate any survival benefit associated with the intra-arrest initiation of hypothermia via LVICS. Our study, the largest study of intra-arrest initiation of hypothermia published to date, failed to demonstrate any effect on survival for out-of-hospital SCA patients, confirming findings of previously published smaller studies. We therefore do not recommend the use of intra-arrest cooling via LVICS infusion as part of routine out-of-hospital SCA resuscitative efforts.

Snakebites are responsible for a significant degree of morbidity and mortality worldwide, especially in low resource countries. There are over 600 identified species of venomous snakes worldwide, with the majority belonging to the Viperidae and Elapidae families. Common names among the Viperidae family are vipers, pit vipers, and adders. Distinguishing features of the Viperidae family include long, retractable fangs, triangular heads, elliptical pupils, and small scales on their tails. The pit vipers also have a heat-sensing pit adjacent to their nares for movement detection to aid in hunting prey.Common names among the Elapid family are cobras, coral snakes, mambas, and copperheads. The Elapids can be distinguished from the Viperids as they have fixed, short fangs, less triangular heads, circular pupils, and larger scales on their tails. The remainder of the venomous snake species belongs to the Atractaspididae, Colubridae, and Hydrophidae families.

Choosing the most appropriate imaging modality for pregnancy patients is a common clinical question encountered daily. The general principle for imaging during pregnancy is similar to imaging for the general population, with the goal of radiation exposure being as low as reasonably achievable (ALARA). What is unique during pregnancy is that fetus radiation exposure is an essential factor in deciding optimal imaging studies. Understanding of consequences of radiation exposure on a fetus, degrees of fetal radiation exposure by each imaging modality, and techniques on reducing fetal radiation exposure is vital in choosing the best diagnostic imaging modality. While it is crucial to minimize fetal radiation exposure as much as possible, it is essential to remember that diagnostic studies should not be avoided for fear of radiation exposure, especially when these studies can dramatically change patient management. This activity will discuss the consequences of radiation exposure on a fetus, degrees of radiation exposure by each modality, and techniques of reducing fetal radiation exposure. Solid understanding of how each imaging modality contributes to fetal radiation dose will significantly help in choosing the most appropriate imaging study that provides the best diagnostic information at the lowest level of radiation exposure.The consequence of radiation exposure in fetuses is mostly based on observations rather than based on scientific research. Ethical issues prohibit researching on the fetus. Therefore, most of the data on the impact of radiation on the fetus derives from observations of patients who suffered Japan’s Hiroshima bombing and the Chernobyl nuclear power plant disaster. [1] [2] Based on the observations made from the victims of the high level of radiation exposure, the consequences of radiation exposure can categorize into four broad groups, including pregnancy loss, malformation, developmental delay or retardation, and carcinogenesis. [1] Pregnancy loss most often happens when radiation exposure happens during early gestation (less than two weeks). [2] Malformations of body parts and developmental delays occur during the organogenesis period (2 weeks to 8 weeks) and are dependent on the radiation dose. [2] Below the threshold level of radiation exposure, there is minimal disruption of organogenesis. Above the threshold, the degree of malformation is related to the dose of the radiation. Lastly, carcinogenesis is considered a stochastic effect. In other words, cancer can develop at any level of radiation exposure. However, the probability of developing cancer increases with the increase in the dose of radiation.In the United States, the background radiation exposure for the whole body per year is estimated to be 3.1 mSv (310 mrem). United States Nuclear Regulation Commission (USNRC) also recommends total fetus exposure during pregnancy to be less than 5.0 mSv (500 mrem). The fetus radiation dose below 50 mGy is considered safe and not cause any harm. According to the Center for Disease Control (CDC), radiation dose between 50 mGy to 100 mGy is regarded inconclusive in terms of impact on the fetus. Doses above 100 mGy, especially doses above 150 mGy, are viewed as the minimum amount of dosage at which negative fetal consequences will occur, based on observation. The majority of the diagnostic studies performed during the pregnancy are below the threshold level.The effect of radiation exposure during pregnancy also depends on the gestational age of the fetus. The embryo/fetus is most susceptible to radiation during organogenesis (2 to 7 weeks gestational age) and in the first trimester. The fetus is more resistant to the radiation during the second and third trimester. Dose between 0.05 to 0.5 Gy is generally considered safe for the fetus during the second and third trimester while it is considered potentially harmful during the 1st-trimester fetus. Even though the fetus is more resistant to the radiation during the second and third trimester, a high dose of radiation (greater than 0.5 Gy or 50 rad) may result in adverse effects including miscarriage, growth reduction, IQ reduction, and severe mental retardation. Therefore, clinicians and radiologists should counsel the pregnant patient regardless of the gestational age. [3] Occupational radiation exposure for a pregnant employee should be monitored to make sure the total amount of radiation exposure is under the regulatory limit. According to the National Council of Radiation Protection and Measurement (NCRP), the total dose equivalent to the embryo/fetus should not exceed 500 mRem during the length of the pregnancy. It should not exceed 50mRem in any month during pregnancy. [4] The practice decision on selecting the most appropriate imaging modality for pregnancy should have their basis in the expert opinions of the treating clinician. Nonetheless, the American College of Radiology does provide recommendations on the appropriateness of imaging modalities in accessing common clinical conditions. Each imaging modality is categories into usually appropriate, may be appropriate, and usually not appropriate. For instance, for a pregnant patient presenting with right lower abdominal pain concerning for appendicitis, ultrasound and MRI are usually appropriate imaging modality. CT abdomen and pelvis with or without contrast is categorized as may be appropriate. Abdominal radiograph, Tc-99m WBC scan, and fluoroscopy contrast enema are considered usually not appropriate. The American College of Radiology appropriateness criteria provides the current practice policies and guidelines in the US regarding imaging in pregnant patients.

PURPOSEThe Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs.METHODSWe analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs.FINDINGSRural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤  .001; 91% urban vs 84% rural; P ≤  .001, respectively).CONCLUSIONSSepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.

STUDY OBJECTIVE:We describe current hospital-level performance for the Centers for Medicare & Medicaid Services' Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) quality measure and qualitatively assess emergency department (ED) sepsis quality improvement best practice implementation.METHODS:Using a standardized Web-based submission portal, we surveyed quality improvement data from volunteer hospital-based EDs participating in the Emergency Quality Network Sepsis Initiative. Each hospital submitted preliminary SEP-1 local chart review data, using existing Centers for Medicare & Medicaid Services definitions. We report descriptive statistics of SEP-1 data availability and performance. The primary outcome for this study was SEP-1 bundle compliance, defined as the proportion of all severe sepsis and septic shock cases receiving all required bundle elements, and secondary outcomes included conditional compliance on reported SEP-1 numerator components and ED implementation of sepsis quality improvement best practices.RESULTS:A total of 50 EDs participated in the survey; 74% were nonteaching sites and 26% were affiliated with academic centers. Of all participating EDs, 80% were in regions with relatively high population density. The mean hospital SEP-1 bundle compliance was 54% (interquartile range 30% to 75%). Bundle compliance improved during fiscal year 2016 from 39% to 57%. Broad variation existed for each bundle component, with intravenous fluid resuscitation and repeated lactate bundle elements having the widest variation and largest gaps in quality. At least one consensus sepsis quality improvement best practice implementation occurred in 92% of participating sites.CONCLUSION:Preliminary data on SEP-1 performance suggest wide hospital-level variation in performance, with modest improvement during the first year of data collection.

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Radiotherapy is useful in the treatment of breast cancer of all stages. Cobalt radiotherapy has been used since the 1950s for breast-cancer management. However, since the advent of linear accelerators, its use has diminished. Post mastectomy radiotherapy has proven survival benefits especially in patients with >4 positive lymph nodes. Among node-positive patients there was a 37% relative reduction of distant metastases with radiation and a 22% relative reduction of death(1). The occurrence of short term and long term complications from exposure to the cobalt radiotherapy including recurrence of cancer, arm paralysis, recurrent laryngeal nerve paralysis and neuropathy depend largely upon the duration of exposure, volume of organs involved and the exposure site(2). We present an extremely rare case of osteomyelitis post cobalt radiotherapy. To our knowledge, this is the first case to be reported of osteoradionecrosis and osteomyelitis developing as a chronic complication post radical mastectomy and cobalt radiotherapy. CASE PRESENTATION: An 89-year-old-female presented with complaints of erythema, yellow discharge and parts of ribs protruding from her upper right chest wall. Patient had bilateral radical mastectomy for breast cancer and underwent cobalt radiotherapy on the right side of chest wall 41 years ago. She had a total of 25 sessions of 1 hour long cobalt radiotherapy on the right chest post mastectomy. Patient was found to have an elevated sedimentation rate of 102 and normal white blood cell count. CT scan of the chest revealed changes suggestive of osteomyelitis and osteoradionecrosis of the right upper ribs. Treatment with IV vancomycin and piperacillin-tazobactam was initiated and plastic surgery consulted. During the admission, patient underwent debridement and resection of necrotic and infected bone and soft tissue. She was discharged with a total of 6 weeks of intravenous antibiotics and follow-up with plastic surgery for skin flap closure at a later date. DISCUSSION: This is a unique and extremely rare long term complication of cobalt radiotherapy. The destructive effects of cobalt radiotherapy and decline in subcutaneous tissue with loss of skin elasticity, which is natural with the aging process likely resulted in the exposed ribs and osteomyelitis. CONCLUSIONS: This unique case helps increase awareness of need for close follow up for surveillance of complications. Reference #1: Auquier A, Rutqvist LE, Rotstein S, Høst H, Arriagada R. Post-mastectomy megavoltage radiotherapy: The Oslo and Stockholm trials. European Journal of Cancer. 1992 Mar 31;28(2):433-7. Reference #2: Johansson S, Svensson H, Denekamp J. Timescale of evolution of late radiation injury after postoperative radiotherapy of breast cancer patients. International Journal of Radiation Oncology* Biology* Physics. 2000 Oct 1;48(3):745-50. DISCLOSURE: The following authors have nothing to disclose: Kairavee Dave, Vivek Choksi, Todd Slesinger, Erin Marra No Product/Research Disclosure Information

Cardiogenic shock is the leading cause of morbidity and mortality in patients presenting with acute coronary syndrome. Although early reperfusion strategies are essential to the management of these critically ill patients, additional treatment plans are often needed to stabilize and treat the patient before reperfusion may be possible. This article discusses pharmacologic and surgical interventions, their indications and contraindications, management strategies, and treatment algorithms.

Objectives Resuscitation often requires rapid vascular access via central venous catheters. Chest radiographyis the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement.Methods A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice.Results Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P<.001). No discrepancy existed between sonographic and radiographic confirmation.Conclusions Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Take-Home MessageAdministration of intravenous magnesium sulfate may result in a modest reduction in hospital admissions among adult ED patients with acute asthma who have not responded to standard therapies.MethodsData SourcesStudies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014.Study SelectionRandomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process.Data Extraction and SynthesisAll 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%).ResultsTablePrimary and secondary outcome measures for intravenous magnesium versus standard therapy.OutcomeNumber of Patients (Studies)OR or Mean Difference (MD) (95% CI)Hospital admission1,769 (11)OR 0.75 (0.60 to 0.92)Length of hospital stay (days)949 (3)MD –0.03 (–0.33 to 0.27)PEF, L/min1,460 (8)MD 17.4 (8.64 to 26.17)PEF, Peak expiratory flow. Open table in a new tab Eleven trials with a total of 1,769 participants provided sufficient information about the primary outcome (hospital admission). Seven of the 11 trials were randomized, double-blind, and placebo controlled; 2 were single-blind; 1 was unblinded with no placebo given; and for 1 trial, the study design was unclear.Compared with controls, patients receiving a single infusion of either 1.2 or 2 g intravenous magnesium sulfate during 15 to 30 minutes experienced a small but significant reduction in rates of hospital admission (odds ratio [OR] 0.75), with minimal heterogeneity observed (I2=28%). When the 3 studies at high or unclear risk of bias for blinding were removed, the pooled effect for hospital admission was similar (OR 0.72; 95% confidence interval [CI] 0.57 to 0.91). There was no significant change in spirometric parameters (eg, peak expiratory flow) as well.All studies included administration of inhaled β2-agonists, and nearly all included administration of oxygen (9 of 11 studies) and corticosteroids (9 of 11 studies) before administration of magnesium, with a subset of patients also receiving inhaled ipratropium bromide (4 of 11 studies). There was no heterogeneity between studies in which ipratropium was and was not administered (I2=0%). Inclusion criteria and the measures used to define an exacerbation were not consistent between studies; the majority of studies used various peak expiratory flow or forced expiratory volume in 1 second (FEV1) cutoffs. The authors could not fully establish how comedication or disease severity affected the treatment effect of magnesium. Adverse events were not consistently reported across studies and most commonly included headache, flushing, nausea, and hypotension, though the authors found no significant mean difference in systolic blood pressures between groups in the 4 studies (N=1,264; mean difference=0.08; 95% CI –1.89 to 2.05).CommentaryAsthma is a chronic disease afflicting approximately 300 million individuals worldwide,2Fanta C.H. Asthma.N Engl J Med. 2009; 360: 1002-1014Crossref PubMed Scopus (373) Google Scholar and asthma exacerbations were responsible for more than 1.7 million ED visits in 2010 in the United States alone.3National Center for Health StatisticsNational Hospital Ambulatory Medical Care Survey (NHAMCS), 2010. Public Health Service, Hyattsville, MD2010Google Scholar Standard therapies include nebulized β2-agonists and corticosteroids, and often inhaled anticholinergics. Intravenous mag-nesium sulfate has been studied as an adjunct therapy, with previous systematic reviews failing to demonstrate significant overall benefit in adults.4Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.Ann Emerg Med. 2000; 36: 181-190Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google ScholarThe results of this systematic review indicate that intravenous magnesium sulfate, when administered in conjunction with standard therapies, may result in a modest reduction in hospital admission among adult patients with acute asthma exacerbations. This review was heavily weighted by Goodacre et al6Goodacre S. Cohen J. Bradburn M. et al.Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial.Lancet Respir Med. 2013; 1: 293-300Abstract Full Text Full Text PDF Scopus (45) Google Scholar (42.6% of the total patient population), who conducted a large, randomized, double-blind, placebo-controlled trial that showed a benefit for intravenous magnesium sulfate on rates of hospital admission (OR 0.70; 95% CI 0.50 to 0.97) when used in conjunction with oxygen, β2-agonists, corticosteroids, and anticholinergics. Differences in how studies categorized disease severity made it difficult to draw conclusions about whether magnesium was more effective in severe asthma compared with moderate asthma, something indicated in subgroup analysis in the previous Cochrane review.5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google ScholarMagnesium is thought to be involved in a number of important cellular processes, including inhibition of calcium influx into respiratory smooth muscle and modulation of acetylcholine release from cholinergic nerve terminals.7Rowe B.H. Intravenous and inhaled MgSO4 for acute asthma.Lancet Respir Med. 2013; 1: 276-277Abstract Full Text Full Text PDF Scopus (14) Google Scholar It is inexpensive, and life-threatening adverse events are rare.8Silverman R.A. Osborn H. Runge J. et al.IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial.Chest. 2002; 122: 489-497Crossref PubMed Scopus (162) Google Scholar Coupled with the moderately persuasive findings of this review, it is reasonable to offer a trial of intravenous magnesium for adult patients with acute asthma who are not responding to standard therapies. Take-Home MessageAdministration of intravenous magnesium sulfate may result in a modest reduction in hospital admissions among adult ED patients with acute asthma who have not responded to standard therapies.MethodsData SourcesStudies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014.Study SelectionRandomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process.Data Extraction and SynthesisAll 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%). Take-Home MessageAdministration of intravenous magnesium sulfate may result in a modest reduction in hospital admissions among adult ED patients with acute asthma who have not responded to standard therapies. Take-Home MessageAdministration of intravenous magnesium sulfate may result in a modest reduction in hospital admissions among adult ED patients with acute asthma who have not responded to standard therapies. Administration of intravenous magnesium sulfate may result in a modest reduction in hospital admissions among adult ED patients with acute asthma who have not responded to standard therapies. MethodsData SourcesStudies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014.Study SelectionRandomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process.Data Extraction and SynthesisAll 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%). MethodsData SourcesStudies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014.Study SelectionRandomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process.Data Extraction and SynthesisAll 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%). Data SourcesStudies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014. Studies were obtained through the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), PsycINFO, and by hand searching of respiratory journals and meeting abstracts through May 2014. Study SelectionRandomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process. Randomized controlled trials comparing any dose of intravenous magnesium sulfate with placebo among adult patients in the emergency department (ED) and with acute asthma exacerbations were reviewed by 3 authors, with a fourth author adjudicating disagreements. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was created to document the study selection process. Data Extraction and SynthesisAll 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%). All 3 authors independently extracted outcome data, using a standardized collection form. Study quality was assessed by Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considerations.1Guyatt G.H. Oxman A.D. Schünemann H.J. et al.GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin Epidemiol. 2011; 64: 380-382Abstract Full Text Full Text PDF PubMed Scopus (1588) Google Scholar Risk of bias was determined according to the Cochrane Handbook for Systematic Reviews of Interventions, with planned sensitivity analysis for studies at high risk of bias for blinding. The authors used a fixed-effect model and performed a sensitivity analysis with random effects when heterogeneity was significant (I2 >30%). ResultsTablePrimary and secondary outcome measures for intravenous magnesium versus standard therapy.OutcomeNumber of Patients (Studies)OR or Mean Difference (MD) (95% CI)Hospital admission1,769 (11)OR 0.75 (0.60 to 0.92)Length of hospital stay (days)949 (3)MD –0.03 (–0.33 to 0.27)PEF, L/min1,460 (8)MD 17.4 (8.64 to 26.17)PEF, Peak expiratory flow. Open table in a new tab Eleven trials with a total of 1,769 participants provided sufficient information about the primary outcome (hospital admission). Seven of the 11 trials were randomized, double-blind, and placebo controlled; 2 were single-blind; 1 was unblinded with no placebo given; and for 1 trial, the study design was unclear.Compared with controls, patients receiving a single infusion of either 1.2 or 2 g intravenous magnesium sulfate during 15 to 30 minutes experienced a small but significant reduction in rates of hospital admission (odds ratio [OR] 0.75), with minimal heterogeneity observed (I2=28%). When the 3 studies at high or unclear risk of bias for blinding were removed, the pooled effect for hospital admission was similar (OR 0.72; 95% confidence interval [CI] 0.57 to 0.91). There was no significant change in spirometric parameters (eg, peak expiratory flow) as well.All studies included administration of inhaled β2-agonists, and nearly all included administration of oxygen (9 of 11 studies) and corticosteroids (9 of 11 studies) before administration of magnesium, with a subset of patients also receiving inhaled ipratropium bromide (4 of 11 studies). There was no heterogeneity between studies in which ipratropium was and was not administered (I2=0%). Inclusion criteria and the measures used to define an exacerbation were not consistent between studies; the majority of studies used various peak expiratory flow or forced expiratory volume in 1 second (FEV1) cutoffs. The authors could not fully establish how comedication or disease severity affected the treatment effect of magnesium. Adverse events were not consistently reported across studies and most commonly included headache, flushing, nausea, and hypotension, though the authors found no significant mean difference in systolic blood pressures between groups in the 4 studies (N=1,264; mean difference=0.08; 95% CI –1.89 to 2.05). PEF, Peak expiratory flow. Eleven trials with a total of 1,769 participants provided sufficient information about the primary outcome (hospital admission). Seven of the 11 trials were randomized, double-blind, and placebo controlled; 2 were single-blind; 1 was unblinded with no placebo given; and for 1 trial, the study design was unclear. Compared with controls, patients receiving a single infusion of either 1.2 or 2 g intravenous magnesium sulfate during 15 to 30 minutes experienced a small but significant reduction in rates of hospital admission (odds ratio [OR] 0.75), with minimal heterogeneity observed (I2=28%). When the 3 studies at high or unclear risk of bias for blinding were removed, the pooled effect for hospital admission was similar (OR 0.72; 95% confidence interval [CI] 0.57 to 0.91). There was no significant change in spirometric parameters (eg, peak expiratory flow) as well. All studies included administration of inhaled β2-agonists, and nearly all included administration of oxygen (9 of 11 studies) and corticosteroids (9 of 11 studies) before administration of magnesium, with a subset of patients also receiving inhaled ipratropium bromide (4 of 11 studies). There was no heterogeneity between studies in which ipratropium was and was not administered (I2=0%). Inclusion criteria and the measures used to define an exacerbation were not consistent between studies; the majority of studies used various peak expiratory flow or forced expiratory volume in 1 second (FEV1) cutoffs. The authors could not fully establish how comedication or disease severity affected the treatment effect of magnesium. Adverse events were not consistently reported across studies and most commonly included headache, flushing, nausea, and hypotension, though the authors found no significant mean difference in systolic blood pressures between groups in the 4 studies (N=1,264; mean difference=0.08; 95% CI –1.89 to 2.05). CommentaryAsthma is a chronic disease afflicting approximately 300 million individuals worldwide,2Fanta C.H. Asthma.N Engl J Med. 2009; 360: 1002-1014Crossref PubMed Scopus (373) Google Scholar and asthma exacerbations were responsible for more than 1.7 million ED visits in 2010 in the United States alone.3National Center for Health StatisticsNational Hospital Ambulatory Medical Care Survey (NHAMCS), 2010. Public Health Service, Hyattsville, MD2010Google Scholar Standard therapies include nebulized β2-agonists and corticosteroids, and often inhaled anticholinergics. Intravenous mag-nesium sulfate has been studied as an adjunct therapy, with previous systematic reviews failing to demonstrate significant overall benefit in adults.4Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.Ann Emerg Med. 2000; 36: 181-190Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google ScholarThe results of this systematic review indicate that intravenous magnesium sulfate, when administered in conjunction with standard therapies, may result in a modest reduction in hospital admission among adult patients with acute asthma exacerbations. This review was heavily weighted by Goodacre et al6Goodacre S. Cohen J. Bradburn M. et al.Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial.Lancet Respir Med. 2013; 1: 293-300Abstract Full Text Full Text PDF Scopus (45) Google Scholar (42.6% of the total patient population), who conducted a large, randomized, double-blind, placebo-controlled trial that showed a benefit for intravenous magnesium sulfate on rates of hospital admission (OR 0.70; 95% CI 0.50 to 0.97) when used in conjunction with oxygen, β2-agonists, corticosteroids, and anticholinergics. Differences in how studies categorized disease severity made it difficult to draw conclusions about whether magnesium was more effective in severe asthma compared with moderate asthma, something indicated in subgroup analysis in the previous Cochrane review.5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google ScholarMagnesium is thought to be involved in a number of important cellular processes, including inhibition of calcium influx into respiratory smooth muscle and modulation of acetylcholine release from cholinergic nerve terminals.7Rowe B.H. Intravenous and inhaled MgSO4 for acute asthma.Lancet Respir Med. 2013; 1: 276-277Abstract Full Text Full Text PDF Scopus (14) Google Scholar It is inexpensive, and life-threatening adverse events are rare.8Silverman R.A. Osborn H. Runge J. et al.IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial.Chest. 2002; 122: 489-497Crossref PubMed Scopus (162) Google Scholar Coupled with the moderately persuasive findings of this review, it is reasonable to offer a trial of intravenous magnesium for adult patients with acute asthma who are not responding to standard therapies. Asthma is a chronic disease afflicting approximately 300 million individuals worldwide,2Fanta C.H. Asthma.N Engl J Med. 2009; 360: 1002-1014Crossref PubMed Scopus (373) Google Scholar and asthma exacerbations were responsible for more than 1.7 million ED visits in 2010 in the United States alone.3National Center for Health StatisticsNational Hospital Ambulatory Medical Care Survey (NHAMCS), 2010. Public Health Service, Hyattsville, MD2010Google Scholar Standard therapies include nebulized β2-agonists and corticosteroids, and often inhaled anticholinergics. Intravenous mag-nesium sulfate has been studied as an adjunct therapy, with previous systematic reviews failing to demonstrate significant overall benefit in adults.4Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature.Ann Emerg Med. 2000; 36: 181-190Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google Scholar The results of this systematic review indicate that intravenous magnesium sulfate, when administered in conjunction with standard therapies, may result in a modest reduction in hospital admission among adult patients with acute asthma exacerbations. This review was heavily weighted by Goodacre et al6Goodacre S. Cohen J. Bradburn M. et al.Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial.Lancet Respir Med. 2013; 1: 293-300Abstract Full Text Full Text PDF Scopus (45) Google Scholar (42.6% of the total patient population), who conducted a large, randomized, double-blind, placebo-controlled trial that showed a benefit for intravenous magnesium sulfate on rates of hospital admission (OR 0.70; 95% CI 0.50 to 0.97) when used in conjunction with oxygen, β2-agonists, corticosteroids, and anticholinergics. Differences in how studies categorized disease severity made it difficult to draw conclusions about whether magnesium was more effective in severe asthma compared with moderate asthma, something indicated in subgroup analysis in the previous Cochrane review.5Rowe B.H. Bretzlaff J.A. Bourdon C. et al.Magnesium sulfate for treating exacerbations of acute asthma in the emergency department.Cochrane Database Syst Rev. 2009; : CD001490Google Scholar Magnesium is thought to be involved in a number of important cellular processes, including inhibition of calcium influx into respiratory smooth muscle and modulation of acetylcholine release from cholinergic nerve terminals.7Rowe B.H. Intravenous and inhaled MgSO4 for acute asthma.Lancet Respir Med. 2013; 1: 276-277Abstract Full Text Full Text PDF Scopus (14) Google Scholar It is inexpensive, and life-threatening adverse events are rare.8Silverman R.A. Osborn H. Runge J. et al.IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial.Chest. 2002; 122: 489-497Crossref PubMed Scopus (162) Google Scholar Coupled with the moderately persuasive findings of this review, it is reasonable to offer a trial of intravenous magnesium for adult patients with acute asthma who are not responding to standard therapies.

TUDY SELECTION andomized controlled trials omparing any dose of intravenous agnesium sulfate with placebo mong adult patients in the mergency department (ED) and ith acute asthma exacerbations ere reviewed by 3 authors, with a ourth author adjudicating isagreements. A Preferred eporting Items for Systematic eviews and Meta-Analyses PRISMA) flow diagram was reated to document the study election process.

Introduction: The 2010 American Heart Association Guidelines stated that “cardiopulmonary resuscitation prompt and feedback devices may be useful for training rescuers and may be useful as part of an overall strategy to improve the quality of CPR for actual cardiac arrests.” We sought to assess the effect of one such device on OOHCA outcomes in a large, urban setting. Methodology: Out-of-hospital cardiac arrest data from two consecutive twelve-month periods was analyzed: August 1, 2010 - July 31, 2011 (control) and August 1, 2011 - July 31, 2012 (CPR feedback). During the CPR feedback period, defibrillators capable of providing real-time audible and visual CPR feedback were added to standard prehospital resuscitation care. Results: There were 850 and 748 bystander witnessed arrests of cardiac etiology in the two periods. Patient and arrest characteristics for the two groups did not differ with respect to age, gender, race, response time, bystander witnessed status, or the frequency of bystander CPR. As compared to the control period, the addition of real-time CPR feedback resulted in a significant improvement in immediate outcomes: return of spontaneous circulation, or ROSC (39.59% vs. 47.71%, p=0.001); sustained ROSC (31.17% vs. 36.14%, p= 0.037). However, there was no improvement in survival to hospital admission (24.88% vs. 25.32%, p=0.85) or survival to hospital discharge (5.63% vs. 6.72%, p=0.43). In addition, among those survivors for whom neurologic status is known, the addition of CPR feedback did not significantly change the proportion of survivors considered neurologically intact (70.37% vs 65.63%, all p=0.78). Conclusions: The addition of real-time CPR feedback to a large urban EMS system’s resuscitation care resulted in significant improvements in immediate survival but did not affect overall survival rates. It is also possible earlier introduction of these devices (through their use by first responder and/or earlier arriving basic life support units) may provide greater benefit. Further data analysis is required to determine the specific effect of CPR feedback devices on long-term survival and to optimize their use in resuscitation care.

Study Objectives: The purpose of this study was to investigate the effect of common sources of infection on outcome in patients with severe sepsis and septic shock in the emergency department (ED).Methods: We conducted a retrospective observational study involving adult patients who were diagnosed with severe sepsis or septic shock in the ED of a tertiary care hospital during the period between August 2008 and March 2012.We categorized patients into four groups based on source of infection (pneumonia, intra-abdominal infection [IAI], urinary tract infection [UTI], and other sources [OS] group).The primary outcome was in-hospital mortality.Multivariable logistic regression analysis was used to adjust potential confounders including age, sex, serum lactate concentrations, the Sequential Organ Failure Assessment score, timely antibiotic use, and achievements of early resuscitation targets.Results: A total of 758 patients were included and overall in-hospital mortality was 16.6%.There were significant differences in mortality between four groups (27.5% for pneumonia, 12.1% for IAI, 2.6% for UTI, and 20.0% for other sources, P<0.01).In patients with IAI, adjusted odds ratios (ORs) for mortality were 0.53 (95% confidence interval [CI], 0.29 -0.98) compared with the OS group and 0.57 (95% CI, 0.36 -0.92) compared with non-IAI.For UTI, adjusted ORs were 0.07 (95% CI, 0.02 -0.28) compared with the OS group and 0.08 (95% CI, 0.02 -0.30) compared with non-UTI.For pneumonia, adjusted ORs were 1.52 (95% CI, 0.84 -2.76) compared with the OS group and 2.86 (95% CI, 1.80 -4.53) compared with non-pneumonia.Conclusions: Our study showed that source of infection was independently associated with in-hospital mortality in patients with severe sepsis and septic shock in the ED.In particular, UTI and IAI were significantly associated with in-hospital survival.Patients with pneumonia showed significantly higher mortality, compared with non-pneumonia patients.

Introduction: In 2005, the Prehospital Evaluation of New York City Survival (PHENYCS) study modest improvements in out-of-hospital cardiac arrest survival as a result of the merger of New York City EMS and the Fire Department of New York. Since that time, numerous changes have been implemented with the intent of further improving survival (e.g. compressions only pre-arrival instructions, ventricular fibrillation waveform analysis in automated defibrillators, emphasis on basic resuscitation, de-emphasis of advanced resuscitation, waveform capnography, resuscitation team leaders, integration of therapeutic hypothermia as a post-resuscitation care standard). We sought to assess the effects of these changes and to describe the current OOHCA survival rates for this large urban system. Methods: We analyzed data from a three-year period (August 1, 2009 - July 31, 2012) and for the purposes of presenting rhythm determination was limited to those OOHCA cases for which paramedics were the first arriving EMS unit. Results: 717 bystander witnessed OOHCA cases of cardiac etiology were followed to hospital discharge. The presenting rhythm were ventricular fibrillation (VF) / ventricular tachycardia (VT) in 19.4%, pulseless electrical activity (PEA) in 24.1%, asystole in 51.6% and other rhythms in 4.9%. As compared to the PHENYCS study, this is a significant reduction the incidence of VF/VT (19.4% vs 24.7%, p=0.005). As compared to the PHENYCS study, there were significant improvements in all survival endpoints: ROSC (38.5% vs 20.2%, p Conclusions: This most recent analysis of OOHCA outcomes for New York City finds that despite a continuing decline in the incidence of VF/VT as the presenting rhythm, there has been a doubling of survival at all endpoints and for all rhythms. Further work is needed to elucidate the causes of this improvement and to further focus OOHCA care on those interventions that are most likely to contribute to survival.

Introduction: The infusion of ice-cold saline (ICS) is often employed for the initiation of therapeutic hypothermia, and many protocols suggest an infusion of up to 30cc/kg in order to achieve one commonly used target temperature range of 32-34 degrees Celcius. We sought to determine if there was any association between ICS volume and core temperature reduction. Methods: We analyzed a convenience sample of out-of-hospital cardiac arrest patients for whom therapeutic hypothermia was being inducted via pressurized ICS infusion and for whom core body temperature was being monitored via an esophageal temperature probe. Results: Esophageal core temperature data was available for 287 patients. The average patient received 1,136ml (SD 472mL) of ICS via pressure infusion. The average core body temperature upon ED arrival was within the identified target range for all patients (33.2oC, SD 2.3 oC). Among patients who received 1500ml (n=48), average core body temperature achieved target range for all groups (33.34 oC, 33.25 oC, 33.5 oC and 32.87 oC, respectively) though there were patients in each group whose core body temperature was either above or below the target range (SD = 2.64 oC, 2.26 oC, 1.34 oC and 2.11 oC, respectively). No correlation was found between the reduction in core body temperature and the infused volume of ICS (ΔT = -0.95 oC±1.52, -1.51 oC ±1.93, -1.40 oC±1.38, -1.45 oC±1.21, respectively). Conclusions: Though perhaps tempered by the disproportionate number of patients in one group, our data would suggest that the relative reduction in and resulting final core body temperature are not a function of the infused volume for patient undergoing the induction of therapeutic hypothermia via ICS infusion. Therefore, if targeted temperature therapy is of clinically important, continuous core temperature monitoring during the induction of cooling is essential to ensure target acquisition.