Background: Extracorporeal membrane oxygenation (ECMO) has several applications as a resuscitative intervention, including extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is rarely initiated in the emergency department (ED) by emergency physicians outside regional academic institutions. Objectives: To evaluate whether ECPR improves clinical outcomes after cardiac arrest when initiated by emergency physicians (EPs) in a nonacademic hospital. Methods and Materials: We performed a retrospective analysis of prospectively identified consecutive EP-initiated ECMO subjects from a single community hospital over a 7-year period. Logistic regression and propensity models tested the association between ECPR and survival to hospital discharge compared with concurrent ECPReligible control subjects. Results: Over 7 years (2010-2017), EPs initiated ECMO on 58 subjects; 44 (76%) were venoarterial cases (43 ECPR) initiated in the ED. Of those, 11 (25%) survived to discharge (n = 9 with cerebral performance category score 1) and most were still alive after 5 years (66%). Adjusting for known covariates, ECPR subjects were more likely than concurrent controls to survive to discharge (odds ratio 8.4; 95% confidence interval 1.2-60.4). Propensity analysis revealed a favorable trend toward survival to discharge after ECPR (odds ratio 2.0; 95% confidence interval 0.51-7.8). Conclusions: Emergency physicians initiated ECMO with promising clinical outcomes. Prospective trials are needed to define the efficacy, safety, and costeffectiveness of EP-initiated ECMO.

Study Objectives: Since 1997, opioid prescribing and unintentional prescription drug deaths have increased dramatically (690% increase in absolute amount of milligrams of morphine equivalents prescribed, 4,030 deaths in 1999 versus 1,600 in 2011). A recent study identified high-dose prescribing as an independent risk factor for opioid death. Multiple state-level chapters of the American College of Emergency Physicians have responded by developing safe opioid prescribing guidelines for emergency departments (ED). However, the ED contribution to this epidemic is incompletely characterized. The goals of this investigation are to estimate the strength of opioid prescriptions and frequency of high-dose prescriptions from the ED compared to other care sites.Methods: We conducted an analysis of the Medical Expenditure Panel Survey (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011), a nationally representative sub-survey of the annual National Health Interview Survey to create the estimates. For each filled prescription, we determined where it was generated (eg, ED versus office) and used the National Drug Code to determine the exact compound and dose of opioids prescribed and converted these to morphine equivalent doses. Patients with ICD-9 codes indicating a history of malignancy were excluded. We used multiple linear regressions with 1) the natural log of the quantity of pills or 2) the natural log of the strength of the compound prescribed as the dependent variables and site of care (eg, ED versus office versus inpatient) as the key independent variable. Several contextual covariates were included to minimize confounding. We next generated unadjusted national estimates of the number of highrisk prescriptions (defined as 100 morphine milligram equivalent [MME] daily) by source of care using a similar framework and finally constructed a multivariate logistic regression model with the probability of receiving a high-dose prescription (defined as 100 MME) as the dependent variable, site-of-care as the key independent variable and similar covariates as above. Using this model, we predicted the proportion of prescriptions that were for 100 MME.Results: We identified 44,313 unique individuals receiving 164,406 opioid prescriptions during the study period. The mean age of individuals included in the study was 48 years and 63% were female. After adjustment for patient demographic features and diagnosis categories, the average opioid prescription originating from the ED dispensed 44% (b ¼-0.44, 95% CI -0.47 to -0.41, P<.001) fewer pills than prescriptions from office visits. On average, the compound prescribed from the ED had 17% (b ¼ -0.17, 95% CI -0.2 to -0.15, P<.001) lower MME than those from office visits. Overall, 1.9% of all opioid prescriptions were for more than 100 MME daily. However, compared with office settings ED prescriptions were much less likely to be for greater than 100 MME per day (0.26% versus 2.62% [odds ratio 0.09, 95% CI 0.05-0.19, P<.001]).Conclusion: EDs prescri...

No abstract

A 52-year-old African American male with a long history of poorly controlled hypertension presented to the emergency department (ED) with two days of genital edema and pain. During ED work-up, the patient developed sudden onset of non-pitting, non-pruritic, and non-urticarial upper lip edema. Review of his antihypertensive medication list revealed that he normally took benazepril, highly suggestive of a diagnosis of angiotensin-converting-enzyme inhibitor-related angioedema (ACEI-RA). We present the first reported case of penile ACEI-RA that progressed to involve the oropharynx. The ED management of the condition and some of the newer treatment options available for ACEI-RA is also briefly discussed.