Objective: Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19 pandemic.Methods: This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID-19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO 2 . SpO 2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non-rebreather mask (NRB) and nasal cannula. We also characterized post-proning failure rates of intubation within the first 24 hours of arrival to the ED.Results: Fifty patients were included. Overall, the median SpO 2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO 2 improved to 94% (IQR 90 to 95). Comparison of the pre-to post-median by the Wilcoxon Rank-sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED.From the

No abstract

Background/Objectives Pain is universal, undertreated, and impedes recovery in hip fracture. This study compared outcomes for regional nerve blocks to standard analgesics following hip fracture. Design Multi-site randomized controlled trial from 4/2009-3/2013. Setting 3 New York hospitals. Participants 161 hip fracture patients. Intervention 79 patients were randomized to receive an ultrasound-guided single injection femoral nerve block administered by emergency physicians at emergency department admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours. 82 control patients received conventional analgesics. Measurements Pain (0-10 scale), distance walked on post-operative day (POD) 3, Walking ability at 6 weeks following discharge, opioid side effects. Results Pain scores 2 hours following emergency department presentation favored the intervention group compared to controls (3.5 versus 5.3 respectively, P=.002). Pain scores on POD 3 were significantly better for the intervention as compared to the control group for pain at rest (2.9 versus 3.8, p=.005), with transfers out of bed (4.7 versus 5.9, p=.005), and with walking (4.1 versus 4.8, p=.002). Intervention patients walked significantly further than controls in 2 minutes on POD 3 (170.6 feet (95% CI 109.3, 232) versus 100.0 feet (95% CI 65.1, 134.9) respectively. P=.041). At 6 weeks, intervention patients reported better walking and stair climbing ability (mean FIM locomotion scores of 10.3 (95% CI 9.6, 11.0) versus 9.1 (95% CI 8.2, 10.0), P=0.045. Intervention patients reported significantly fewer opioid side effects (3% versus 12.4%, P=.028) and required 33-40% fewer parenteral morphine sulfate equivalents. Conclusion Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Acute aortic dissection (AAD) is a rare and lethal disease with presenting signs and symptoms that can often be seen with other high risk conditions; diagnosis is therefore often delayed or missed. Pain is present in up to 90% of cases and is typically severe at onset. Many patients present with acute on chronic hypertension, but hypotension is an ominous sign, often reflecting hemorrhage or cardiac tamponade. The chest x-ray can be normal in 10-20% of patients with AAD, and though transthoracic echocardiography is useful if suggestive findings are seen, and should be used to identify pericardial effusion, TTE cannot be used to exclude AAD. Transesophageal echocardiography, however, reliably confirms or excludes the diagnosis, where such equipment and expertise is available. CT scan with IV contrast is the most common imaging modality used to diagnose and classify AAD, and MRI can be used in patients in whom the use of CT or IV contrast is undesirable. Recent specialty guidelines have helped define high-risk features and a diagnostic pathway that can be used the emergency department setting. Initial management of diagnosed or highly suspected acute aortic dissection focuses on pain control, heart rate and then blood pressure management, and immediate surgical consultation.

No abstract