Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. Methods: We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015-2019 were retrospectively included and analyzed. Results: We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2-13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. Conclusion: Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.
Clinical informatics (CI) is a rich field with longstanding ties to resident education in many clinical specialties, although a historic gap persists in emergency medicine. To address this gap, we developed a CI track to facilitate advanced training for senior residents at our 4-year emergency medicine residency. We piloted an affordable project-based approach with strong ties to operational leadership at our institution and describe specific projects and their outcomes. Given the relatively low cost, departmental benefit, and unique educational value, we believe that our model is generalizable to many emergency medicine residencies. We present a pathway to defining a formal curriculum using Kern's framework.
Spinal injury has the potential to dramatically change a patient’s life. Prompt diagnosis, appropriate supportive medical care, early transfer to a spinal injury center and, if necessary, surgical intervention within 24 hours are essential to optimizing outcomes. Clinical decision rules aid in determining the need for imaging. When needed, non-contrast enhanced CT is the initial imaging test of choice with MRI being used in patients with neurologic findings, significant pathology on CT, and/or high suspicion for injury. CT or MRI with intravenous contrast is preferred in penetrating trauma. Radiographs are of limited utility in evaluating spinal injury in adults. Classification of spinal injury based on appearance on imaging and neurologic exam is important for surgical management decisions. Cervical injury may lead to respiratory distress requiring early intubation. Hypotension is most often a result of hemorrhage from concomitant traumatic injuries to other organ systems. Crystalloid, blood products, atropine and norepinephrine should be used as needed to avoid systolic BP< 90 mm Hg or heart rate< 60 BPM and maintain a MAP of 85-90 mm Hg. Steroid administration within the first 8 hours of significant spinal injury is controversial and the decision to administer steroids should be made through consultation with patient, family and spinal specialist. The review contains 8 figures, 2 videos, 13 tables, and 59 references. Keywords: blunt trauma, neurologic assessment, penetrating trauma, spinal anatomy, spinal cord injury, spinal injury, steroid use, vertebrae, vertebral anatomy, vertebral injury
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