Admission Vital Signs Research Articles

Validating the GO-FAR score: predicting in-hospital cardiac arrest outcomes in the Middle East

Introduction and aimExternal validations of the Good Outcome Following Attempted Resuscitation (GO-FAR) score have been in populations where Do Not Attempt Resuscitation (DNAR) is practised. We aim to externally validate the GO-FAR score in a population without a DNAR order.MethodsWe studied patients ≥ 18 years old who had an In-hospital cardiac arrest (IHCA) with known outcomes at Al Ain Hospital from January 2017 to December 2019, excluding those who died in the emergency department. Studied variables included demography, location, response time, code duration, initial rhythm, primary diagnosis, admission vital signs, GO FAR score variables, discharge status, and functional outcomes as determined by the cerebral performance category score ranging from 1 (good cerebral performance) to 5 (brain death).Results366 patients were studied; 66.7% were males. The median (IQR) age was 70 (55–81) years. Cardiac and respiratory causes were the primary diagnoses in 89 (24.6%) and 67 (18.5%), respectively. IHCA occurred in critical areas such as the intensive care unit, high dependency unit and coronary care unit in 206 (80.8%) patients. The majority, 308 (91.8%), had a non-shockable rhythm, and a return of spontaneous circulation was achieved in 159 (43.4%) of the patients. Thirty-one (8.5%) patients survived to hospital discharge, and 20 (5.5%) patients had cerebral performance category scores of 1 and 2. The area under the curve of the ROC for survival to discharge with good functional outcome was 0.74 (95% CI 0.59–0.88). The best cut-off point for predicting survival with a good neurological outcome was a GO-FAR score of < 4, having a sensitivity of 0.81, a specificity of 0.7, a positive likelihood ratio of 2.7 and a negative likelihood ratio of 0.27.ConclusionsA GO-FAR score of less than 4 predicts survival with a good neurological outcome in a healthcare system with an all-inclusive patient population with no DNAR practice.

A Case of Forgotten Poisoning in a Patient Presenting with Speech Disorder

Anticholinergic poisoning is one of the most common causes of poisoning in the emergency department. Beautiful hawthorn (atropa belladonna), which is found in our country, is one of the plants that can cause anticholinergic syndrome. It is important in the differential diagnosis in cases progressing with general status disorder and loss of consciousness and psychotic findings. The onset of anticholinergic intoxication varies depending on the toxin and occurs within one to two hours following oral ingestion. The diagnosis of anticholinergic poisoning is based on clinical findings. Anticholinergic poisoning is easily diagnosed when a history of exposure to an anticholinergic substance is obtained and the patient shows altered mental status, delirium or hallucinations. However, in cases with no history and unknown exposure, the diagnosis of anticholinergic intoxication is considered when clinical signs and symptoms caused by mental status disorder and anticholinergic effects are detected on physical examination. A 75-year-old woman was admitted to the emergency department with complaints of slurred speech, altered consciousness and facial shifting that started about 2 hours ago. On physical examination, the patient was incoopere and disoriented, GCS:12 eyes were spontaneously open, obeying orders but making unintelligible sounds, nuchal rigidity was suspiciously positive, bilateral babinski reflex was positive. On admission vital signs were blood pressure 144/72 mmHg, pulse 98/min, temperature 37 °C, SO2 94%, fingerstick blood glucose 104 mg/dl and ECG was in normal sinus rhythm. There were no acute pathologic findings on both brain CT and brain MR imaging. In the control physical examination, both pupils were mydriatic, IR -/- and the patient had dry mouth. According to the anamnesis obtained from another relative of the patient, it was learned that they ate spinach in the evening and speech disorder started afterwards. The patient was diagnosed with anticholinergic intoxication considering that the spinach eaten by the patient with clinical findings might have been mixed with the beautiful hawthorn weed. In this case report, we aimed to emphasize the importance of detailing the anamnesis and the necessity of a complete systemic examination in patients presenting with confusion and speech disorder.

Evaluation of pediatric trauma score and pediatric age-adjusted shock index in pediatric patients admitted to the hospital after an earthquake.

In our earthquake-prone country, it is crucial to gather data from regional hospitals following earthquakes. This information is essential for preparing for future disasters and enhancing healthcare services for those affected by earthquakes. This study aimed to evaluate the Pediatric Trauma Score (PTS) and the Shock Index, Pediatric Age-Adjusted (SIPA), in children affected by earthquakes, to provide clinicians with insights into the severity of trauma and hemodynamic stability. The study included patients admitted to our hospital's pediatric emergency service within the three weeks following the earthquake. We evaluated their age, sex, admission vital signs, mechanical ventilation requirements, development of crush syndrome, length of hospital stay, PTS, and SIPA. Our study included 176 children (89 females and 87 males) with trauma. Fifty-eight (32.95%) children had crush syndrome, and 87 (49.43%) were hospitalized. The median PTS was 10 (ranging from -3 to 12), and the median SIPA was 1.00 (ranging from 0.57 to 2.10). We observed a negative correlation between the time spent under debris and PTS (r=-0.228, p=0.002) and a positive correlation with the SIPA score (r=0.268, p<0.001). The time spent under debris (p<0.001) and SIPA score (p<0.001) were significantly higher in hospitalized children. PTS was significantly lower in hospitalized children than in others. A PTS cutoff point of 7.5, and a SIPA cutoff point of 1.05, predicted hospitalization in all children. Time spent under debris and SIPA were significantly higher in children with crush syndrome than in others (p<0.001). PTS at a cutoff point of 8.5 and SIPA at a cutoff point of 1.05 predicted crush syndrome in all children. PTS and SIPA are important practical scoring systems that can be used to predict the severity of trauma, hospitalization, crush syndrome, and the clinical course in pediatric patients admitted to the hospital due to earthquake trauma.

Endovascular Repair of Ruptured Aortic Aneurysm: A Single-Center Experience.

Aortic rupture is a rare and catastrophic emergency. Prompt diagnosis and treatment are the primary determinants of mortality. During follow-up, the majority of patients who have been effectively treated die from hypovolemic shock and multiorgan failure. This article describes the clinical and procedural details of sixteen patients with ruptured aortic aneurysms treated endovascularly. In addition, it discusses the main factors contributing to the mortality of these patients. Patients who underwent endovascular treatment for acute aortic rupture at our center from October 2016 to March 2023 were included in this retrospective study. A total of 16 patients underwent endovascular aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) for acute aortic rupture. The patients' mean age was 73.06 years (range: 52-92), and 15 of them were male. The ruptures occurred in the abdominal aortic aneurysm in ten patients, in thoracic aortic aneurysm in three patients, in the isolated iliac artery aneurysm in two patients, and there was one case of non-aneurysmal aortic rupture. In our series, patients who presented with an impending, self-limited rupture and stable hemodynamic status had good prognostic outcomes. However, eight patients died due to multiorgan failure, hemorrhagic shock, disseminated intravascular coagulopathy, renal failure, or abdominal compartment syndrome. These patients generally had poor admission vital signs and low hemoglobin values. The most critical determinants for the success of the procedure are promptly stopping the bleeding, avoiding general anesthesia, and opting for blood product replacement instead of fluid replacement. Each patient with ruptured aortic aneurysm should be managed according to the patient's hemodynamics at presentation, the size of the aneurysm, the suitability for percutaneous procedure, logistical factors, and the operator-center's experience.

Impact of Surge Strain and Pandemic Progression on Prognostication by an Established COVID-19–Specific Severity Score

IMPORTANCE: Many U.S. State crisis standards of care (CSC) guidelines incorporated Sequential Organ Failure Assessment (SOFA), a sepsis-related severity score, in pandemic triage algorithms. However, SOFA performed poorly in COVID-19. Although disease-specific scores may perform better, their prognostic utility over time and in overcrowded care settings remains unclear. OBJECTIVES: We evaluated prognostication by the modified 4C (m4C) score, a COVID-19–specific prognosticator that demonstrated good predictive capacity early in the pandemic, as a potential tool to standardize triage across time and hospital-surge environments. DESIGN: Retrospective observational cohort study. SETTING: Two hundred eighty-one U.S. hospitals in an administrative healthcare dataset. PARTICIPANTS: A total of 298,379 hospitalized adults with COVID-19 were identified from March 1, 2020, to January 31, 2022. m4C scores were calculated from admission diagnosis codes, vital signs, and laboratory values. MAIN OUTCOMES AND MEASURES: Hospital-surge index, a severity-weighted measure of COVID-19 caseload, was calculated for each hospital-month. Discrimination of in-hospital mortality by m4C and surge index-adjusted models was measured by area under the receiver operating characteristic curves (AUC). Calibration was assessed by training models on early pandemic waves and measuring fit (deviation from bisector) in subsequent waves. RESULTS: From March 2020 to January 2022, 298,379 adults with COVID-19 were admitted across 281 U.S. hospitals. m4C adequately discriminated mortality in wave 1 (AUC 0.779 [95% CI, 0.769–0.789]); discrimination was lower in subsequent waves (wave 2: 0.772 [95% CI, 0.765–0.779]; wave 3: 0.746 [95% CI, 0.743–0.750]; delta: 0.707 [95% CI, 0.702–0.712]; omicron: 0.729 [95% CI, 0.721–0.738]). m4C demonstrated reduced calibration in contemporaneous waves that persisted despite periodic recalibration. Performance characteristics were similar with and without adjustment for surge. CONCLUSIONS AND RELEVANCE: Mortality prediction by the m4C score remained robust to surge strain, making it attractive for when triage is most needed. However, score performance has deteriorated in recent waves. CSC guidelines relying on defined prognosticators, especially for dynamic disease processes like COVID-19, warrant frequent reappraisal to ensure appropriate resource allocation.

Hemophagocytic Lymphohistiocytosis As an Immune-Related Adverse Events in a Patient with Advanced Lung Adenocarcinoma

I ntroduction: Immune checkpoint inhibitors (ICIs) have been approved as single agents or in combination with cytotoxic chemotherapy for use in the treatment of different tumor types including skin, lung, kidney, endometrium, bladder..., especially in advanced stages. ICIs are usually well tolerated and despite their demonstrated clinical benefit, severe immune-related adverse events (irAEs) can sometimes occur, including colitis, hepatitis, myocarditis, glomerulonephritis, pneumonitis, hypophysitis... Here we are reporting a case of hemophagocytic lymphohistiocytosis (HLH), a rare but potentially life-threatening complication of ICI therapy. Case presentation: We present the case of a 60-year-old female with metastatic adenocarcinoma of left lung who presented to the emergency room with a week history of generalized weakness, worsening dyspnea on exertion and decreased appetite while on maintenance ICI with pembrolizumab for approximately 1 year. On admission vital signs were a blood pressure of 88/70mmhg, pulse rate of 139 beats per minute, respiratory rate of 20 cycles per minute, temperature of 98.3°F and oxygen saturation of 98% on room air. Physical exam was unremarkable. A complete blood count revealed leukopenia of 2.7k/uL, hemoglobin of 11.8 g/dL, and mild thrombocytopenia of 131k/uL. A basic metabolic panel was significant for hyponatremia of 133 mmol/L, blood urea nitrogen of 43mg/dL, and creatinine of 1.71mg/dL. She was started on empiric broad-spectrum antibiotics with IV vancomycin and cefepime due to concern for infection in the setting of recurrent febrile episodes and neutropenia. Worsening pancytopenia prompted further work-up and showed elevated ferritin of 19581, lactate dehydrogenase of 2380, folate &amp;gt; 20, vitamin B 12 of 1645, iron level of 62, elevated total and direct bilirubin of 6.3 and 2.9 mg/dL, haptoglobin &amp;lt; 10 mg/dL, fibrinogen level of 174, C- reactive protein of 73.9. Elevated soluble IL2- receptor elevated at 10336.7, d-dimer &amp;gt; 20, elevated partial thromboplastin time of 51.1, Prothrombin Time of 20.5, INR of 1.7. Peripheral blood smear was unremarkable. Hemophagocytic lymphohistiocytosis was suspected and a bone marrow was performed prior to initiation of intravenous steroids. Bone marrow showed evidence of abundant histiocytes with hemophagocytosis of nucleated cells. She was discharged on an oral steroid taper. She has since been well without evidence of tumor progression off therapy for over 2 years now. Discussion: HLH is a rare but potentially life-threatening complication of ICI therapy that requires prompt recognition and management. Our patient responded well to steroids and did not require cytotoxic chemotherapy with etoposide.

Abstract 348: Machine Learning Approaches for Early Outcome Risk Stratification Within 6 Hours of Cardiac Arrest

Background: Formal prognostication should be delayed at least 72 hours after cardiac arrest, but early stratification of risk severity provides important information for medical decision making, research enrollment, and precision medicine. Hypothesis: EEG-derived indices are valid biomarkers of severity of injury after cardiac arrest and contribute to early identification of risk. Aims: To assess the relative impact of early clinical data and processed EEG indices in the first 6 hours after recovery of spontaneous circulation (ROSC). Methods: Data from the first 6 hours after ROSC in the International Cardiac Arrest Registry (INTCAR) from Maine Medical Center including demographics, cardiac arrest data, admission vital signs and laboratory results and processed EEG indices at 6 hours after ROSC (bispectral index or BIS6 and suppression ratio or SR6) were extracted. Cerebral Performance Category (CPC) scores at hospital discharge and 6-month follow-up were dichotomized into good (CPC = 1-2) and poor (CPC = 3-5) outcomes. Three models were trained, one with INTCAR data, a second with EEG data, and the third combining INTCAR and BIS6-SR6. Six machine learning algorithms were applied: Catboost, random forest, Xgboost, Adaboost, support vector machine and logistic regression. Variable importance was analyzed by the decrease of impurity of random forest. Results: Among 913 included patients, median age was 59 years (95%CI 23-85), 623 (68%) were male, initial rhythm was shockable in 405 (44%) patients, and average time to ROSC was 23 (95%CI 3 - 73) minutes. Survival to hospital discharge occurred in 41% (364/893), and poor outcome occurred in 72.7% at 6-month follow-up (607/835). For CPC at discharge, area-under-the curve (AUC) was 0.85 for the combined INTCAR and EEG data, greater than INTCAR (AUC = 0.80) or EEG (AUC = 0.77). For the CPC at follow-up, the AUC was 0.88 for the combined data, greater than INTCAR (AUC = 0.83) or EEG (AUC = 0.79). Variable ranking analysis showed that BIS6 and SR6 were the two most informative features for both outcomes. Conclusions: The processed EEG variables BIS6 and SR6 significantly contribute to risk identification in the first 6 hours after ROSC, and combined with early clinical data provide reliable risk stratification.

Predicting 90-Day Prognosis in Ischemic Stroke Patients Post Thrombolysis Using Machine Learning.

(1) Objective: This study aimed to construct a machine learning model for predicting the prognosis of ischemic stroke patients who underwent thrombolysis, assessed through the modified Rankin Scale (mRS) score 90 days after discharge. (2) Methods: Data were sourced from Qatar's stroke registry covering January 2014 to June 2022. A total of 723 patients with ischemic stroke who had received thrombolysis were included. Clinical variables were examined, encompassing demographics, stroke severity indices, comorbidities, laboratory results, admission vital signs, and hospital-acquired complications. The predictive capabilities of five distinct machine learning models were rigorously evaluated using a comprehensive set of metrics. The SHAP analysis was deployed to uncover the most influential predictors. (3) Results: The Support Vector Machine (SVM) model emerged as the standout performer, achieving an area under the curve (AUC) of 0.72. Key determinants of patient outcomes included stroke severity at admission; admission systolic and diastolic blood pressure; baseline comorbidities, notably hypertension (HTN) and coronary artery disease (CAD); stroke subtype, particularly strokes of undetermined origin (SUO); and hospital-acquired urinary tract infections (UTIs). (4) Conclusions: Machine learning can improve early prognosis prediction in ischemic stroke, especially after thrombolysis. The SVM model is a promising tool for empowering clinicians to create individualized treatment plans. Despite limitations, this study contributes to our knowledge and encourages future research to integrate more comprehensive data. Ultimately, it offers a pathway to improve personalized stroke care and enhance the quality of life for stroke survivors.

SAT139 Non-insulinoma Pancreatogenous Hypoglycemia Syndrome In A Patient With 1p36 Deletion Syndrome

Abstract Disclosure: E.D. Auckley: None. M.A. Arosemena: None. L. Philipson: None. Background: 1p36 deletion syndrome comprises a phenotypic presentation that includes central nervous system, cardiac, and craniofacial anomalies. There has been no report of associated hypoglycemia with this syndrome. Nesidioblastosis, also known as non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), is understood as a rare condition defined by diffuse pancreatic hypertrophy with subsequent hyperinsulinemic hypoglycemia. Diagnosis requires serologic workup consistent with endogenous hyperinsulinemic hypoglycemia, intraarterial calcium stimulation positive for inappropriately elevated insulin secretion, and imaging studies without identified masses. Clinical Case: A 21-year-old female with 1p36 deletion syndrome (seizure disorder, cerebral palsy, vision loss and heart failure) was admitted to the hospital due to persistent falls. On admission vital signs were within normal limits, and physical exam revealed a thin non-verbal patient without significant other findings. During hospitalization and prolonged fasting periods of approximately 14-18 hours related to poor appetite she developed several episodes of hypoglycemia with serum glucose as low as 57 mg/dl. As patient was non-verbal at baseline, symptoms of hypoglycemia such as sweating, lightheadedness or shakiness were not confirmed. Even when she started to eat, hypoglycemic events continued to occur. Dextrose containing fluids (Dextrose 5% and later 10%) were added to try to maintain blood sugars within the normal range. Nevertheless, she continued to develop hypoglycemia. Endocrinology service was consulted and recommended to obtain a critical sample. A critical sample revealed serum glucose of 59 mg/dl, insulin level of 20.6 mcU/mL, proinsulin of 33 pmol/L, and beta-hydroxybutyrate of &amp;lt;0.10 mmol/L. Insulin antibodies was negative. Adrenal insufficiency was unlikely due to a normal 9 am cortisol level of 13.7 ug/dl. Due to the presence of hyperinsulinemic hypoglycemia further workup was conducted. A CT of the abdomen with a pancreatic protocol and 68Ga-DOTATATE PET/CT scan was negative for a pancreatic mass. Endoscopic ultrasound did not reveal a clear pancreatic mass either. This was followed by a calcium stimulation test which showed a two-fold increase in insulin levels in all 3 catheterized pancreatic territories. In the absence of a discrete mass, non-surgical management was recommended. For hypoglycemia management patient was started on octreotide injections with resolution of hypoglycemia. Prior to discharge she was switched to lanreotide and was discharged to continue monthly lanreotide injections. Conclusion: To our knowledge, this is the first case reported of NIPHS in a patient with a mutation in 1p36 deletion. Hyperinsulinism in the setting of diabetes has been reported in this syndrome1 but to our knowledge no cases of hypoglycemia with NIPHS have been reported. Presentation: Saturday, June 17, 2023

15 Hospital at home—a potential alternative option to acute hospital admission for older adults

Abstract Background Novel ways to respond to the acute care needs of older adults are needed. Hospital at Home (H@H) could be a viable alternative to emergency hospitalisation. We developed inclusion and exclusion criteria for selected medical conditions that could theoretically be treated in a hospital at home setting if supported by a geriatric medicine multidisciplinary team with a consultant, Advanced Nurse Practitioner (ANP), Physiotherapist (PT) and Cccupational Therapist (OT). Methods We completed a retrospective cohort study of unselected medical admissions over a two week period in a level four hospital. We developed illness specific criteria for stable patients that if met could allow a patient to be treated in a hospital at home environment. These conditions included community acquired pneumonia, congestive cardiac failure, COPD exacerbation and urinary tract infection. Results There were 307 medical admissions over the study period, with 144 over the age of 75 (47%). Mean age 83.2. 59 patients met our inclusion criteria for a potential H@H service (41%). All patients were clinically stable based on admission vital signs. The mean length of stay was shorter for patients eligible for H@H than patients who did not meet the criteria (9 days vs 14 days, p 0.01), and patients meeting the H@H criteria were more likely to be discharged home directly. They were less likely to have needed occupational therapy (32% vs 52%, p = 0.02) or medical social worker input (22% vs 42%). There was no difference in frailty category or readmission rates by whether or not a patient met the H@H criteria. Conclusion Over 40% of unselected medical take patients were of a low acuity that could have theoretically met our inclusion criteria for a supported hospital at home model. Strategies are needed to support expansion of this model of care.

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial.

Tranexamic acid (TXA) use has been associated with thrombotic complications. We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA). The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation. 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation. Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

PS-P05-2: THE CORRELATION OF HYPERTENSION WITH LENGTH OF STAY OF ADHF IN CVCU OF SAIFUL ANWAR GENERAL HOSPITAL, MALANG, INDONESIA

Background: Long-term hypertension eventually leads to heart failure (HF), and therefore, most patients with HF have a history of hypertension. Conversely, the absence of hypertension in midlife was associated with a lower risk of new-onset heart failure later in life. Cardiac remodeling with major pressure overload includes diastolic dysfunction and concentric left ventricular (LV) hypertrophy. If pressure overload persists, diastolic dysfunction progresses and concentrically remodeled left ventricular filling decreases, followed by heart failure with preserved ejection fraction. Objectives: The aim of this study was to ascertain the correlation of pre-existence hypertension with the length of stay (LOS) of acute decompensated heart failure (ADHF) patients admitted in CVCU of Dr. Saiful Anwar General Hospital, Malang. Method: The study was a retrospective analytic in ADHF patients in CVCU of Dr. Saiful Anwar General Hospital Malang in August 2021 to April 2022. The presence of pre-existence hypertension in admission were compared with non-hypertensive group. Result: A total of 86 patients met study criteria in August 2021 to April 2022, respectively. The prevalence of hypertensive group ADHF patients was 61.6% (53 of 86), with comparable rates for men (74.4% [64 of 86]) and women (25.6% [22 of 86]). The LOS rate was higher in hypertensive group (11 days in average) than non-hypertensive group ADHF patients (8 days in average). Conclusion: The prevalence of hypertension as comorbid of heart failure patients is higher than the non-hypertensive heart failure group in CVCU of Dr. Saiful Anwar Malang in August 2021 to April 2022. Based on admission vital signs, patients with longer LOS have hypertension as pre-exsistence comorbid.

566: DESCRIPTIVE ANALYSIS OF OBSTETRIC PATIENTS WITH PULMONARY EMBOLISM AT A SINGLE TERTIARY CENTER

Introduction: Obstetric patients with pulmonary embolism (PE) are at higher risk of severe maternal morbidity and mortality. There is limited data validating current PE scoring systems in the obstetric population. We performed a descriptive study comparing the clinical characteristics and maternal and neonatal outcomes of the PERT consults in all of our female patients in reproductive age, by their pregnancy status. Methods: We identified all female patients in reproductive age (18 to 55) between 1/2019 to 5/2022, and divided by pregnancy status. Electronic medical records were used to collect clinical characteristics and treatment modalities. The primary outcome was survival at 30 days. Secondary outcomes included echocardiogram and CTA findings, admission vital signs, BOVA score procedural and neonatal outcomes. Univariable analysis was performed to compare characteristics and primary outcomes. Results: A total of 106 PERT consults were reported. 6 patients were pregnant. At the time of PE diagnosis the mean gestational age was 23w3d (SD). Two patients were delivered with 1 maternal death. Obstetric patients were younger than non-pregnant patients (33.8 vs. 41.9, p= 0.06). There was no statistical difference in right ventricular (RV) strain by CT (46% vs, p= 0.85), initial heart rate (102 vs. 111, p= 0.28), systolic blood pressure (102 vs. 119, p= 0.08), elevated troponin (50% vs. 61%, p= 0.59), or presence of massive PE (16.7% vs. 16%, p= 0.97). Standard Bova score points were also similar (2.2 vs. 2.1, p= 0.78) corresponding to a grade of 1, low risk. There were more low risk consults in the pregnant group (33.3% vs. 5%, p= 0.007). On initial TTE, there was no difference in RV dilation, function, RVSP, or TAPSE between the groups. Each group also had similar of rates transfer to ICU and interventions on arrival. Survival at 30 days was lower in the pregnant group (83.3% vs. 98%, p= 0.04). Conclusions: Despite similar demographic, hemodynamic, and TTE characteristics between all patients in reproductive age, our study suggest that obstetric patients with PE are at a higher risk of death. Indicating that traditional triage and management guidelines for patients with PE lack reproducibility in the obstetric population. New risk factors need to be identified for outcome predictors in obstetric patients.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania

BackgroundDamage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. MethodsWe analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for “reopening of recent laparotomy” or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. ResultsIn total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. ConclusionThere is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

Early Mortality Risk in Acute Trauma Patients: Predictive Value of Injury Severity Score, Trauma Index, and Different Types of Shock Indices.

Objective: This study aimed to explore the predictive value of the Injury Severity Score (ISS), Trauma Index (TI) and different types of shock indices (SI) on the early mortality risk of acute trauma patients. Methods: Clinical data of acute trauma patients who met the inclusion and exclusion criteria of this study and were treated in the hospital from January 2020 to December 2020 were retrospectively collected, including gender, age, trauma mechanism, severe injury site, ISS, TI, admission vital signs, different types of shock indices (SI), death within 7 days, length of hospital stay, and Glasgow Outcome Score (GOS). The predictive value of the Injury Severity Score, Trauma Index, and different types of shock indices on the risk of early mortality in patients with acute trauma were compared using relevant statistical methods. Results: A total of 283 acute trauma patients (mean age 54.0 ± 17.9 years, 30.74% female) were included, and 43 (15.19%) of the patients died during 7 days of hospitalization. The admission ISS, TI, SI, MSI, and ASI in the survival group were significantly lower than those in the death group, and the difference was statistically significant (p < 0.05). Meanwhile, different trauma assessment tools included in the study have certain predictive value for early mortality risk of trauma patients. Conclusions: The TI indicates a better capability to predict the risk of early death in patients with acute trauma. As the most sensitive predictor, the SI has the greatest reference value in predicting the risk of early death in patients with traumatic shock.

EVALUATION OF SERIAL BIOMARKERS IN INTERMEDIATE-RISK PATIENTS WITH ACUTE PULMONARY EMBOLISM

EVALUATION OF SERIAL BIOMARKERS IN INTERMEDIATE-RISK PATIENTS WITH ACUTE PULMONARY EMBOLISM

Platelet Transfusion and Outcomes After Massive Transfusion Protocol Activation for Major Trauma: A Retrospective Cohort Study.

Incorporation of massive transfusion protocols (MTPs) into acute major trauma care has reduced hemorrhagic mortality, but the threshold and timing of platelet transfusion in MTP are controversial. This study aimed to describe early (first 4 hours) platelet transfusion practice in a setting where platelet counts are available within 15 minutes and the effect of early platelet deployment on in-hospital mortality. Our hypothesis in this work was that platelet transfusion in resuscitation of severe trauma can be guided by rapid turnaround platelet counts without excess mortality. We examined MTP activations for all admissions from October 2016 to September 2018 to a Level 1 regional trauma center with a full trauma team activation. We characterized platelet transfusion practice by demographics, injury severity, and admission vital signs (as shock index: heart rate/systolic blood pressure) and laboratory results. A multivariable model assessed association between early platelet transfusion and mortality at 4 hours, 24 hours, and overall in-hospital, with P <.001. Of the 11,474 new trauma patients admitted over the study period, 469 (4.0%) were massively transfused (defined as ≥10 units of red blood cells [RBCs] in 24 hours, ≥5 units of RBC in 6 hour, ≥3 units of RBC in 1 hour, or ≥4 units of total products in 30 minutes). 250 patients (53.0%) received platelets in the first 4 hours, and most early platelet transfusions occurred in the first hour after admission (175, 70.0%). Platelet recipients had higher injury severity scores (mean ± standard deviation [SD], 35 ± 16 vs 28 ± 14), lower admission platelet counts (189 ± 80 × 10 9 /L vs 234 ± 80 × 10 9 /L; P < .001), higher admission shock index (heart rate/systolic blood pressure; 1.15 ± 0.46 vs 0.98 ± 0.36; P < .001), and received more units of red cells in the first 4 hours (8.7 ± 7.7 vs 3.3 ± 1.6 units), 24 hours (9 ± 9 vs 3 ± 2 units), and in-hospital (9 ± 8 vs 3 ± 2 units) than nonrecipients (all P < .001). We saw no difference in 4-hour (8% vs 7.8%; P = .4), 24-hour (16.4% vs 10.5%; P = .06), or in-hospital mortality (30.4% vs 23.7%; P = .1) between platelet recipients and nonrecipients. After adjustment for age, injury severity, head injury, and admission physiology/laboratory results, early platelet transfusion was not associated with 4-hour, 24-hour, or in-hospital mortality. In an advanced trauma care setting where platelet counts are available within 15 minutes, approximately half of massively transfused patients received early platelet transfusion. Early platelet transfusion guided by protocol-based clinical judgment and rapid-turnaround platelet counts was not associated with increased mortality.

Admission vital signs as predictors of COVID-19 mortality: a retrospective cross-sectional study

BackgroundCOVID-19 remains a major healthcare concern. Vital signs are routinely measured on admission and may provide an early, cost-effective indicator of outcome – more so in developing countries where such data is scarce. We sought to describe the association between six routinely measured admission vital signs and COVID-19 mortality, and secondarily to derive potential applications for resource-limited settings.MethodsRetrospective analysis of consecutive patients admitted to King Edward VIII Hospital, South Africa, with COVID-19 during June–September 2020 was undertaken. The sample was subdivided into survivors and non-survivors and comparisons made in terms of demographics and admission vital signs. Univariate and multivariate analysis of predictor variables identified associations with in-hospital mortality, with the resulting multivariate regression model evaluated for its predictive ability with receiver operating characteristic (ROC) curve analysis.ResultsThe 236 participants enrolled comprised 153(77.54%) survivors and 53(22.46%) non-survivors. Most participants were Black African(87.71%) and female(59.75%) with a mean age of 53.08(16.96) years. The non-survivor group demonstrated a significantly lower median/mean for admission oxygen saturation (%) [87(78–95) vs. 96(90–98)] and diastolic BP (mmHg) [70.79(14.66) vs. 76.3(12.07)], and higher median for admission respiratory rate (breaths/minute) [24(20–28) vs. 20(20–23)] and glucose (mmol/l) [10.2(6.95–16.25) vs. 7.4(5.5–9.8)]. Age, oxygen saturation, respiratory rate, glucose and diastolic BP were found to be significantly associated with mortality on univariate analysis. A log rank test revealed significantly lower survival rates in patients with an admission oxygen saturation < 90% compared with ≥90% (p = 0.001). Multivariate logistic regression revealed a significant relationship between age and oxygen saturation with in-hospital mortality (OR 1.047; 95% CI 1.016–1.080; p = 0.003 and OR 0.922; 95% CI 0.880–0.965; p = 0.001 respectively). A ROC curve analysis generated an area under the curve (AUC) of 0.778 (p < 0.001) when evaluating the predictive ability of oxygen saturation, respiratory rate, glucose and diastolic BP for in-hospital death. This improved to an AUC of 0.832 (p < 0.001) with the inclusion of age.ConclusionA multivariate regression model comprising admission oxygen saturation, respiratory rate, glucose and diastolic BP (with/without age) demonstrated promising predictive capacity, and may provide a cost-effective means for early prognostication of patients admitted with COVID-19 in resource-limited settings.

Investigation of poor prognostic markers in covid-19 patients hospitalized from emergency department

On March 11. 2020, the World Health Organization declared the coronavirus disease-2019 (COVID-19) outbreak a pandemic. The surge in the number of infected patients has strained healthcare systems globally. The insufficient number of hospital and intensive care unit (ICU) beds has caused a serious problem in patient care and follow-up worldwide. We determined patients who were admitted to the emergency department and hospitalized with a preliminary diagnosis of COVID-19 between March 11, 2020 and November 15, 2020. We recorded all subjects' admission vital signs, anamnesis, physical examination notes, laboratory tests and notes describing the hospital stay from the hospital information system. Patients discharged without requiring ICU admission were included in the good clinical prognosis (GCP) group. Patients who were admitted to the ICU or died in hospital were included in the poor clinical prognosis (PCP) group. When hematological and biochemical parameters were compared, white cell, neutrophil, platelet counts, glucose, urea, creatinine and bilirubin levels were significantly higher and lymphocyte count, hemoglobin, hematocrit, sodium and chlorine levels were lower in the PCP group. Moreover, sedimentation, C Reactive Protein (CRP), ferritin, High Sensitive Troponin I, D-dimer and lactate levels were significantly higher among patients with a poor prognosis. We assessed and identified the more important potential early indicators of prognosis mentioned in the literature that are applicable in the emergency setting. In light of this information, we aimed to establish a basis for the development of future scoring systems.

Clinical findings predictive of maternal adverse outcomes with pyelonephritis

BACKGROUNDPyelonephritis, a leading cause of infection during pregnancy, is associated with increased maternal adverse outcomes. Therefore, early recognition and intervention of pyelonephritis are important. Early recognition of pyelonephritis has historically been dependent on fever and costovertebral angle tenderness. However, the reliability of these findings to distinguish women who will develop maternal adverse outcomes is limited. OBJECTIVEThis study aimed to identify clinical variables on presentation that are predictive of maternal adverse outcomes associated with pyelonephritis during pregnancy. STUDY DESIGNA retrospective cohort study of pregnant women admitted with pyelonephritis at a single hospital from October 1, 2015, to July 31, 2021, was conducted. The primary outcome was a composite maternal adverse outcome consisting of any of the following: maternal intensive care unit admission, surgical intervention, hypotension requiring vasopressors, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, altered mental status, dialysis, organ failure, venous thromboembolism, or maternal death. Differences in maternal characteristics and clinical signs and symptoms on admission were stratified by the presence or absence of a maternal adverse outcome. Categorical variables were analyzed using the Fisher exact test. Continuous data were analyzed with Wilcoxon rank-sum test. Sensitivity and specificity and likelihood ratios with 95% confidence intervals were calculated for the detection of maternal adverse outcomes by specified admission physical examination and laboratory findings. RESULTSOf 97 women that met the inclusion criteria, 28 (28.9%) had maternal adverse outcomes. Moreover, 50 of 97 women (51.5%) had fever on presentation, with no difference between cohorts recognized. Admission vital signs were not significantly different between cohorts. Costovertebral angle tenderness was present in 78 of 97 women (80.4%) on presentation, with no difference between cohorts. Compared with women without a maternal adverse outcome, women with maternal adverse outcomes were more likely to have leukocytosis (18/28 [64.3%] vs 20/69 [29.0%]), thrombocytosis (3/28 [10.7%] vs 5/69 [7.2%]), bandemia (8/28 [28.6%] vs 7/69 [10.1%]), and an abnormal serum potassium (20/28 [71.4%] vs 32/63 [50.8%]). CONCLUSIONAdmission vital signs may not reliably identify women with pyelonephritis at risk of maternal adverse outcomes. Laboratory studies, particularly a complete blood count and electrolytes, may provide a means of distinguishing those at risk of maternal adverse outcomes.