Objectives Acute dyspnea is a common presenting complaint to the emergency department (ED), and point‐of‐care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B‐lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. Methods A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In‐Process & Other Non‐Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand‐searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case‐control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B‐lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B‐lines. A final diagnosis from clinical follow‐up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS‐2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. Results Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B‐lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. Conclusions This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B‐lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.

Objectives: Alternative-level metrics (Altmetrics) are a new method to assess the sharing and spread of scientific knowledge. The primary objective of this study was to describe the traditional metrics and Altmetric scores of the 50 most frequently cited articles published in emergency medicine (EM) journals. Since many articles related to EM are published in other journals, the secondary aim of this study was to describe the Altmetric scores of the most frequently cited articles relevant to EM in other biomedical journals.Methods: A structured search of the Institute for Scientific Information Web of Science version of the Science Citation Index Expanded was conducted. The 200 most frequently cited articles in the top 10 EM journals (2011 Journal Citation Report) were identified. The 200 most frequently cited articles from the rest of the medical literature, matching a predefined list of keywords relevant to the specialty of EM, were identified. Two authors reviewed the lists of citations for relevance to EM and a consensus approach was used to arrive at the final lists of the top 50 cited articles. The Altmetric scores for the top 50 cited articles in EM and other journals were determined. Descriptive statistics and Spearman correlation were performed.Results: The highest Altmetric score for EM articles was 25.0; the mean (AESD) was 1.9 (AE5.0). The EM journal with the highest mean article Altmetric score was Resuscitation. The main clinical areas shared for articles from EM articles were trauma (mean AE SD = 11.0 AE 15.6, median = 11.0) and cardiac arrest (mean AE SD = 2.7 AE 5.8, median = 0). The highest Altmetric score for other journals was 176.0 (mean AE SD = 23.3 AE 40.8). The other journal with the highest mean article Altmetric score was the New England Journal of Medicine. The main clinical areas shared for articles were critical care (mean AE SD score = 36.5 AE 47.4, median = 36.5), sepsis (mean AE SD = 24.6 AE 48.8, median = 12.0), cardiology (mean AE SD = 19.2 AE 35.6, median = 7.0), and infectious diseases (mean AE SD = 17.0 AE 12.7, median = 17.0). Spearman correlation demonstrated weakly positive correlation between citation counts and Altmetric scores for EM articles and other journals.Conclusions: This study is the first analysis of Altmetric scores for the top cited articles in EM. We demonstrated that there is a mild correlation between citation counts and Altmetric scores for the top papers in EM and other biomedical journals. We also demonstrated that there is a gap between the sharing of the top articles in EM journals and those related to EM in other biomedical journals. Future research to explore this relationship and its temporal trends will benefit the understanding of the reach and dissemination of EM research within the scientific community and society in general.ACADEMIC EMERGENCY MEDICINE 2016;23:251-268

Bystander automated external defibrillator use before emergency medical services arrival in shockable observed public OHCA was associated with better survival and functional outcomes. Continued emphasis on public automated external defibrillator utilization programs may further improve outcomes of OHCA.

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Background: Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. Methods: In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. Results: Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06–1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5–9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02–1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7–8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66–1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74–1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.

ED-based diagnostic research for dementia screening is limited to a few studies using an inadequate criterion standard with variable masking of interpreter's access to the index test and the criterion standard. Standardizing the geriatric ED cognitive assessment methods, measures, and nomenclature is necessary to reduce uncertainties about diagnostic accuracy, reliability, and relevance in this acute care setting. The AMT-4 is currently the most accurate ED screening instrument to increase the probability of dementia and the Brief Alzheimer's Screen is the most accurate to decrease the probability of dementia. Dementia screening as one marker of vulnerability to initiate comprehensive geriatric assessment is warranted based on test-treatment threshold calculations.

In this study, concussion rates were not significantly different for varsity football and rugby players who wore the WIPSS Brain-Pad mouth guard compared with other types of mouth guards.

We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation.Methods: We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) þ3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS -1. Secondary outcomes included the need for rescue medications and serious adverse events.Results: Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). Conclusion:In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol. [