What is the Role of Sugammadex in the Emergency Department?

BackgroundSugammadex is a medication newly available to many emergency physicians. It effectively, and within minutes, reverses neuromuscular blockade in patients who have received rocuronium or vecuronium. The role of sugammadex for the reversal of neuromuscular blockade after rapid sequence intubation in the emergency department (ED) is evolving, and limited emergency medicine-specific literature exists.ObjectiveThis narrative review evaluates the role of sugammadex for the reversal of neuromuscular blockade in the ED.DiscussionThe basic pharmacology, duration of action, adverse effects, and important medication and disease interactions specific to sugammadex are well described. Case reports suggest sugammadex can reverse neuromuscular blockade to facilitate an urgent, neurologic examination by an emergency physician or consultant. Multiple case reports of failure to improve airway patency with the use of sugammadex, even when neuromuscular blockade is completely reversed, and concern for added difficulty of definitive airway management in a patient with spontaneous movement suggest that sugammadex should largely be omitted from failed or difficult airway management strategies. Instead, it is important to focus on the ability to oxygenate and ventilate, including progression to surgical airway or jet ventilation if needed.ConclusionSugammadex is an effective, rapid reversal agent for rocuronium and has the potential use to facilitate an urgent neurologic examination shortly after administration of rocuronium. Its routine inclusion in a failed or difficult emergency airway is not supported by available literature.     

What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department?

Background

Australian Emergency Departments are experiencing increased numbers of clients with a mental illness and Emergency Departments are becoming increasingly utilised as the first point of contact and portal into the mental health care system. Therefore nurses working within the Emergency Departments find themselves having to care for clients with a mental illness as part of their daily work. The aim of this study was to gain an understanding of the experiences of Emergency Department nurses caring for clients with a mental illness in the Emergency Department.

Methods

An interpretive phenomenological study was undertaken using semi structured interviews to enable the lived experiences of Emergency Department nurses to be discovered and articulated. Six Registered Nurses working within an Emergency Department were interviewed, and these participants were asked to tell the story of their experiences in their own words.

Results

Results are based on data collected from six participant interviews. Three major themes emerged related to caring for clients with a mental illness in the Emergency Department: (i) Time as a causative factor, (ii) environment and the influence of surroundings and (iii) understanding the client's personal journey.

Conclusions

Data obtained from participants in this study confirm what has been reported in the literature, that is, that there has been an increase in presentations of clients with a mental illness to the Emergency Department, and the results of this study highlight that time constraints specific to the Emergency Department impact both the client with the mental illness and the Emergency Department nurse caring for these clients. In addition, narratives from Emergency Department nurses purport that the environment within the Emergency Department is not conducive to the provision of optimal care to this client group who have unique care needs and require a specialised management focus. Furthermore, the participants expressed that they had difficulty conceptualising the role of the Emergency Department in the client's personal journey. The concept of recovery in mental health comes into conflict with the culture within the Emergency Department that views recovery as a restoration or return to health rather than the unique journey of the client living with a mental illness.     

What is the Role of Reversal Agents in the Management of Emergency Department Patients with Dabigatran-Associated Hemorrhage?

Background

In 2010, the U.S. Food and Drug Administration (FDA) approved dabigatran as the first non-warfarin oral anticoagulant for use in the United States. At the time of FDA approval, there was no antidote or effective treatment for dabigatran-induced hemorrhage. In 2015, the FDA approved idarucizumab for the treatment of dabigatran-induced hemorrhage. The purpose of this clinical practice statement is to evaluate the role of select reversal agents in the management of patients with dabigatran-associated bleeding.

When is a door not a door? The difference between documented and actual arrival times in the emergency department

Objectives

An observational study to determine the difference between documented ambulance arrival times and the actual arrival times of patients from the ambulance into the emergency department.

Methods

In a busy, purpose built, modern emergency department with easy access, we recorded the time that ambulance borne patients were wheeled over the threshold of the clinical area and compared this to the times recorded by the ambulance trusts as the official ambulance arrival times.

Results

352 ambulance arrivals were observed. Data were incomplete in 34 instances (9.5%) and were not included in the analysis. For the remaining 318 arrivals, the median time difference was 2 min 1 s (range 5 s to 21 min 45 s). In a subgroup of chest pain patients (45 patients), the median time difference was 2 min 11 s (range 23 s to 5 min 38 s). The difference between the chest pain group and the remaining patients was not significant (p = 0.528).

Conclusions

There is inevitably some delay between the arrival of an ambulance and the arrival of the patient into a clinical area. This study quantifies that difference. In an era of stringent time related standards, this paper highlights the need for accurate recording of times to enable us to carry out valid audit of these standards. This study supports the redefining of an arrival time as the time when the patient arrives in the clinical area.     

When is a placebo effect not an effect?

It is often stated, paradoxically, that a treatment is not effective when trials have shown a placebo effect. This should be rephrased 'that the tested treatment is not more effective than the placebo' if we are not to confuse ourselves and the public in the current debate on complementary and alternative medicine.     

Women’s Experiences of Miscarriage in the Emergency Department

IntroductionMiscarriage is a common event, usually managed in the emergency department. Although studies have examined the impact of miscarriage on women’s mental health and the effects of their dissatisfaction with health care received, little is known about the characteristics of the miscarriage experience in the emergency department. The objective of this study was to identify characteristics of care management that may have contributed to the difficulties experienced by women presenting with miscarriage in the emergency department.MethodsForty-eight women treated at 4 emergency departments in different regions of Quebec, Canada, were interviewed for 60 to 90 minutes. A thematic qualitative analysis of these interviews was performed.ResultsAnalyses revealed that participants’ experiences were characterized particularly by a lack of information at 3 critical junctures of the miscarriage experience: the announcement of the miscarriage, the course of the miscarriage, and the ED discharge. The topics on which the women lacked information were categorized into 7 subthemes within these junctures.DiscussionLack of information throughout the care management of miscarriage exacerbated the already-difficult nature of this event for the participants. Training emergency nurses to give adequate and complete information enables the delivery of compassionate care, potentially making a difficult situation less traumatic.     

Whats that noise? Bedside monitoring in the Emergency Department

ObjectiveTo determine the frequency, duration and type of audible monitor alarms in an ED, utilising the standard manufacturer’s classification.MethodsThe audible monitor alarms and the timing of any intervention related to the patient monitoring was observed and recorded.Results110 Patients admitted to the Majors area or Resuscitation Room were observed for a total of 93 hours. One monitor was observed at a time. Alarm noise was generated 29% of the observation time. Overall, 429 alarms lasting 21 hours 27 minutes were judged to be positive and 143 alarms lasting 5 hours 47 minutes, negative. 74% of Resuscitation Room and 47% of Majors alarms were silenced or paused. Alarm limit parameters were only adjusted after 5% of alarms in Resuscitation Room and 6% of alarms in Majors.ConclusionsWhilst high level monitoring is desired from a patient safety perspective, it contributes to a significant ambient noise level, which is recognised by all who pass through an ED, and can be detrimental to patients, relatives and staff. We have demonstrated that there is a high probability of near-continuous alarm noise from patient monitoring in a 10-bedded Majors area. We make suggestions for methods of noise reduction and intend to implement some of these within our own ED.     

When is bioavailable testosterone a redundant test in the diagnosis of hypogonadism in men?

OBJECTIVES: Total testosterone (TT) is frequently prescribed with an SHBG and/or free or bioavailable testosterone measurement. Our objective was to identify a TT range for which subsequent SHBG measurement/calculation adds no additional clinical information. DESIGN AND METHODS: Study data were composed of 3955 sets of TT, SHBG and calculated bioavailable testosterone (cBAT) results from unscreened ambulatory male subjects, aged 18-99. RESULTS: 90% of mismatches between TT and cBAT were observed with TT levels between 6.5 and 13.0 nmol/L, with only slight age variation and no important change with albumin level. SHBG measurement restricted to male patients with TT between 6.5 and 13.0 nmol/L should enable reagent cost savings of over 55%. CONCLUSION: We suggest that a TT level below 6.5 nmol/L or above 13.0 nmol/L provides sufficient useful information for ruling out hypogonadism in ambulatory adult males. This strategy of BAT testing should lead to significant time and cost savings.     

Domestic Abuse in the Emergency Department: Can a Risk Profile Be Defined?

OBJECTIVES: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse. METHODS: This study was a crosssectional survey of 611 women conducted in an academically-affiliated, urban ED. Domestic abuse was described as "recent" (within the preceding 12 months) or "lifetime" (recent or past). This included emotional, physical, and sexual abuse. RESULTS: Recent (7.9%, n = 48) and lifetime (38%, n = 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n = 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7). CONCLUSIONS: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.     

It's all in a name. When is a 'Delphi study' not a Delphi study?

As nursing researchers we need to fully understand the origins of the methods we are using in research investigations. Without an in-depth understanding, we may find ourselves violating fundamental underpinning assumptions or conventions through ignorance, and the resulting studies are unlikely to stand up to tests of congruence and rigour. This paper is a discussion of some complexities encountered while exploring the literature on the Delphi technique, a research method we had believed to be straightforward. The Delphi method had been used extensively since its development in the 1950s, and its use in nursing research appears to be increasing. Our explorations revealed that, rather than a simple means of obtaining the judgments of experts, modifications and adaptations over the years have dramatically changed 'the' Delphi. Anyone wishing to use the method needs a sound knowledge of complex theoretical issues associated with its implementation.