ED Arrival Research Articles

Abstract TP160: Use Of Tele-stroke In A Large Integrated Healthcare System Demonstrate No Disparities In Endovascular Treatment For Stroke

Background: Race and sex disparities have been reported in endovascular stroke treatment, the most effective treatment to prevent long-term disability from stroke associated with large vessel occlusion (LVO). In this study, we sought to determine if there are racial and sex disparities in endovascular stroke treatment for patients with acute ischemic stroke due to LVO across 21 community hospitals, part of an integrated delivery system, using a centralized telestroke service and standardized process for rapid stroke evaluation and treatment. Methods: Study population included patients seeking care for suspected acute stroke that were diagnosed with a LVO at one of 21 Northern California Emergency Departments between January 1, 2016 and December 31, 2019. Patients were excluded if they were less than 18 years of age or had a canceled stroke alert. Logistic regression (SAS proc genmod) was used for multivariate models. Results: Of 1519 patients with LVO, 918 underwent endovascular treatment. There were no differences in sex, Healthcare membership (yes or no), or race in patients that received endovascular stroke treatment compared to those that did not in the multi-variate models (Table). As expected, increased age, greater initial NIHSS (greater than 6), arrival by Emergency Medical Service (yes or no), and shorter time to ED arrival were associated with increased treatment rates (Table). There were no significant differences by race or sex. There were no differences in 90-day mortality rates by race (p=0.085). Non-treatment was primarily associated with patient/family refusal and or poor functioning at baseline. Conclusions: Implementation of the telestroke plus standardized workflows within all facilities provided equitable care regarding race and gender on endovascular treatment odds.

Abstract TP154: Impact Of Non-English Primary Language On Mechanical Thrombectomy Outcomes

Background: Delays in acute treatment of ischemic stroke have been associated with worse outcomes. Ischemic stroke patients with non-English primary language have not been shown to have delay in receiving thrombolytic therapy. We assessed whether non-English primary language was associated with functional outcomes in patients receiving mechanical thrombectomy (MT). Method: This is a retrospective study of our MT database from two comprehensive stroke centers from January 2016 to May 2021. Primary endpoints were discharge and 90-day modified Rankin Scale (mRS) 0-2. Descriptive statistics were used to summarize the demographic and clinical characteristics, means and standard deviation or median and the 25th and 75th percentiles for continuous variables and frequency and percentages for categorical variables. Differences between primary English speaking (ES) and primary non-English speaking (nES) patients were evaluated using an analysis of variance (ANOVA), Kruskal-Wallis and chi square test. Multivariable logistic regression was used to evaluate ES vs nES patients adjusted for age, hemoglobin A1c, tPA treatment, and TICI 2B/3 reperfusion which were selected a priori. The significance level was set at 0.05. Result: We identified 276 patients receiving MT with 83% ES and 17% nES patients. nES patients had higher mean hemoglobin A1c, were less likely to have insurance, and more likely to have symptomatic intracranial hemorrhage compared to ES patients (Table). No differences were observed in discharge or 90-day mRS in the univariate and multivariable logistic regression. We observed a nominally longer median ED arrival to groin puncture time in the nES group. Conclusion: There was no difference between nES and ES in good functional outcome rates in patients treated with MT. The trend toward longer ED length of stay in non-English language patients warrants additional study to identify specific causes of delay that may be targeted for intervention.

Prognostication of COVID-19 patients using ROX index and CURB-65 score - A retrospective observational study.

Coronavirus disease-2019 (COVID-19) disease has overwhelmed the healthcare infrastructure worldwide. The shortage of intensive care unit (ICU) beds leads to longer waiting times and higher mortality for patients. High crowding leads to an increase in mortality, length of hospital stays, and hospital costs for patients. Through an appropriate stratification of patients, rational allocation of the available hospital resources can be accomplished. Various scores for risk stratification of patients have been tried, but for a score to be useful at primary care level, it should be readily available at the bedside and be reproducible. ROX index and CURB-65 are simple bedside scores, requiring minimum equipment, and investigations to calculate. This retrospective, record-based study included adult patients who presented to the ED from May 1, 2020 to November 30, 2020 with confirmed COVID-19 infection. The patient's clinical and demographic details were obtained from the electronic medical records of the hospital. ROX index and CURB-65 score on ED arrival were calculated and correlated with the need for hospitalization and early (14-day) and late (28-day) mortality. 842 patients were included in the study. The proportion of patients with mild, moderate and severe disease was 46.3%, 14.9%, and 38.8%, respectively. 55% patients required hospitalization. The 14-day mortality was 8.8% and the 28-day mortality was 20.7%. The AUROC of ROX index for predicting hospitalization was 0.924 (p < 0.001), for 14-day mortality was 0.909 (p < 0.001) and for 28-day mortality was 0.933 (p < 0.001). The AUROC of CURB-65 score for predicting hospitalization was 0.845 (p < 0.001), for 14-day mortality was 0.905 (p < 0.001) and for 28-day mortality was 0.902 (p < 0.001). The cut-off of ROX index for predicting hospitalization was ≤18.634 and for 14-day mortality was ≤14.122. Similar cut-off values for the CURB-65 score were ≥1 and ≥2, respectively. ROX index and CURB-65 scores are simple and inexpensive scores that can be efficiently utilised by primary care physicians for appropriate risk stratification of patients with COVID-19 infection.

Primary PCI in Patients Admitted with Cardiogenic Shock and STEMI: Outcome and Predictors of In-hospital Mortality

<i>Background</i>: It is a well-known phenomenon that cardiogenic shock (CS) is a serious complication of acute myocardial infarction. The mortality rate is approximately 50% even with rapid revascularization, optimal medical care, and use of mechanical support. <i>Aim of the Work</i>: To investigate the outcome of primary percutaneous coronary intervention (PCI) in patients admitted with cardiogenic shock and ST-segment elevation myocardial infarction (STEMI) and the predictors of in-hospital mortality. <i>Patients and Methods</i>: This prospective, observational study was conducted in the national heart Institute, Alazhar University, and Military hospitals in the period from 6/2019 to 9/2021 on fifty six consecutive patients presenting to Alazhar University hospitals, National Heart Institute (NHI), Military hospitals. <i>Results</i>: The prevalence of dyslipidemia and diabetes mellitus were significantly higher among died patients than those who survived. The degree of LV impairment was significantly higher among patients who died than those who survived. As regard to PCI procedure characteristics, TIMI flow post PCI (<Grade III), multi-vessel disease, and procedural failure were significantly associated with high in-hospital mortality rate. Patients who received treatment with IABP were significantly older. <i>Conclusion</i>: Multi-vessel coronary artery disease, TIMI flow after PCI (grade III), and ↑ CK-MB (72-hour serial measurement), were all found to be significant predictors of in-hospital mortality. The onset from chest pain to ED arrival and the door-to-balloon time were higher than that reported in the previous studies. The use of IABP was not found to have a significant predictor effect on the different outcome among our patients with STEMI.

Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy

Introduction : Mobile Stroke Units (MSUs) speed thrombolytic treatment for acute ischemic stroke and improve clinical outcomes compared to standard management by Emergency Medical Services (EMS). However, MSU process metrics in the subset of patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) have yet to be optimized. Methods : A pre‐specified Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU) substudy of tPA‐eligible stroke patients with imaging evident LVOs was conducted. The primary outcome was process metrics related to treatment times from stroke onset and first medical alert. Safety outcomes included rates of symptomatic intracerebral hemorrhage and procedural complications. Groups were compared using Chi‐square or Fisher’s exact tests for categorical variables, and Wilcoxon rank‐sum tests for continuous variables. Results : A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU mean 19.0 [IQR 13.0,23.0] vs EMS 16.0 [11.0, 20.0], p = 0.003). 92% of MSU and 87% of EMS LVO patients received tPA, and 78% and 85% went on to have EVT. Process metrics are detailed in Table 1. MSU LVO patients had faster tPA bolus from 911‐alert (MSU 45.0 minutes [40.0, 53.5] vs EMS 76.0 [64.0, 87.8], p&lt;0.001), however the two groups had similar alert to groin puncture (MSU 142.5 [116.8, 171.0] versus EMS 131.5 [114.0, 159.8], p = 0.15). MSU patients spent more time on‐scene, (EMS arrival to ED arrival, 53.0 [45.0, 62.0] vs 27.0 [22.0, 33.0], p&lt;0.001) however less time prior to EVT (door to groin puncture, 76.5 [54.8, 108.5] vs 94.0 [72.0, 123.0], p&lt;0.001) with variable use of field CTAs and direct cath lab admission with ED bypass, yielding a net neutral result. The variability among site protocols is reflected in the range of median alert to groin puncture times (minimum 107.0 minutes, maximum 152.0). In the 222 patients undergoing EVT, median alert to recanalization time was 181.5 minutes [146.8, 225.5] in the MSU group and 190.5 [157.5, 227.5] in the EMS group (p = 0.47). Recanalization (Thrombolysis In Cerebral Infarction [TICI] 2b/3) was achieved in 76% of MSU and 70% of EMS (p = 0.32) with comparable rates of EVT complications (including hemorrhage, perforation, dissection, hematoma). 54% MSU and 44% of EMS LVO patients achieved good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days (p = 0.11). Conclusions : In tPA‐eligible LVO stroke patients, MSU management did not increase or expedite EVT treatment times as compared to standard EMS management. Future MSU processes should include field CTA with direct admission to cath labs to maximize the early treatment advantage this technology provides.

Abstract 1122‐000147: Factors associated with the Delayed Door to Puncture Time for the Basilar Artery Occlusion patient

Introduction : Performing mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence‐based. In the real‐world practice, it is also often encountered that the delayed initiation of the MT happens for this particular patient groups due to lack of cortical signs and other medical confounding factors. Methods : We retrospectively analyzed the angiographical and clinical outcomes of consecutive BAO patient who underwent MT in single institution. Onset to treatment (OTT), Door to Puncture (DTP) time were compared with those in anterior circulation large vessel occlusion (ACLVO) group who underwent MT in the same time period. For those showed significantly longer DTP time, the factors associated with the delayed initiation of the MT were analyzed. Results : A total of 271 patients underwent mechanical thrombectomy at UCI Medical Center between Jan 2016 and June 2021. Of these, 32 patients diagnosed as BAO by CTA and underwent MT were included in the study. Successful recanalization was achieved in 28 cases (87.5%), and symptomatic ICH occurred in 3 cases (9.4%). Nine patients (28.1%) showed good clinical outcomes (mRS 0–3) at 3 months. The median Onset to Puncture Time (OTT) was 340 min. The median DTP time (145 min) was significantly longer as compared to the ACLVO patients (99 min) (p value = 0.04). Of the 6 patients who showed significant delay in the initiation of intervention (DTP&gt;300 min), 5 patients (83.3%) did not have the initial “stroke‐code activation” at the time of ED arrival. The cause of the delay was due to lack of cortical sign (3), bilateral spontaneous sustained clonus, which misinterpreted as seizure (1), AMS with non‐focal neurological signs interpreted as encephalopathy (2). Conclusions : DTP of the patients who underwent MT for BAO was significantly longer than that in ACLAO. Lack of cortical sings which are markers of ACLVO were associated with delayed activation of stroke code. Establishment of BAO screening in the ED assessment and prompt activation of Stroke code may contribute to the improvement of MT treatment for the BAO patients.

Hypofibrinogenaemia and hypocalcaemia in adult trauma patients receiving pre-hospital packed red blood cell transfusions: Potential for supplementary pre-hospital therapeutic interventions.

To report the arrival ionised calcium (iCa) and fibrinogen concentrations in trauma patients treated with packed red blood cells by the road-based high-acuity response units of a metropolitan ambulance service. A retrospective review of trauma patients treated with packed red blood cells by high-acuity response units between January 2012 and December 2016. Patients were identified from databases at southeast Queensland adult trauma centres, Pathology Queensland Central Transfusion Laboratory, Gold Coast University Hospital blood bank and the Queensland Ambulance Service. Patient characteristics, results of laboratory tests within 30 min of ED arrival were analysed. A total of 164 cases were analysed. The median injury severity score was 33.5 (interquartile range 22-41), with blunt trauma the commonest mechanism of injury (n=128, 78.0%). Fifty-eight of the 117 patients (24.4%) with fibrinogen measured had a fibrinogen concentration ≤1.5g/L; 79 of the 123 patients (64.2%) with an international normalised ratio (INR) measurement had an INR >1.2; 97 of 148 patients (63.8%) with an iCa measured, had an iCa below the Pathology Queensland reference range of 1.15-1.32 mmol/L. Arrival fibrinogen concentration ≤1.5g/L and arrival iCa ≤1.00 were associated with in-hospital mortality with odds ratio11.90 (95% confidence interval 4.50-31.65) and odds ratio4.97 (95% confidence interval 1.42-17.47), respectively. Hypocalcaemia and hypofibrinogenaemia on ED arrival were common in this cohort. Future work should evaluate whether outcomes improve by correction of these deficits during the pre-hospital phase of trauma care.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes.

There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions. This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity. Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori. To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

EOSINOPHILIC PNEUMONIA AND EXTENDED-RELEASE INJECTABLE NALTREXONE

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Extended-release injectable naltrexone is an opioid antagonist approved for the treatment of alcohol and opioid dependence. Since the release of the drug in 2006, a literature review reveals five reported cases of drug-induced eosinophilic pneumonia. Our case highlights the clinical presentation of drug-induced eosinophilic pneumonia in the setting of extended-release injectable naltrexone. CASE PRESENTATION: A 35-year-old female with a past medical history lifelong tobacco use and alcohol dependence on extended-release injectable naltrexone presented to the ED with subjective fevers, myalgias, cough, and pleuritic chest pain. She was evaluated at urgent care two days prior and sent home on a course of Levofloxacin for bronchitis. Upon ED arrival, she was noted to be hypoxic and placed on supplemental oxygen. She was afebrile and tachycardic. Exam was pertinent for tachypnea and bilateral crackles. Initial laboratory data revealed WBC 19,500 (neutrophil predominate) and lactic acid 1.4. Chest x-ray and chest CT demonstrated extensive bilateral infiltrates. Empiric antibiotics were initiated while awaiting microbiology data. Due to escalating oxygen requirements and hemodynamic instability over the next 24 hours, the patient was intubated and bedside bronchoscopy was completed. BAL studies revealed lymphocyte predominance (46%) followed by eosinophils (27%) and neutrophils (21%). Given concern for acute eosinophilic pneumonia in the setting of extended-release injectable naltrexone, corticosteroids were started. Antibiotics were discontinued given negative culture data and our patient showed marked clinical improvement with continuation of steroid therapy. DISCUSSION: Extended-release injectable naltrexone is a long-acting opioid antagonist approved for the treatment of alcohol dependence. Clinical trials showed one diagnosed case & one suspected case of naltrexone-induced eosinophilic pneumonia. A current medical literature review reveals a paucity of cases associated with naltrexone and drug-induced AEP. While the etiology & pathogenesis remain largely unknown, it is thought to be related to an acute hypersensitivity reaction to an antigen in a genetically susceptible person. Progression from mild dyspnea to overt respiratory failure is rapid. Initial diagnostics are often nonspecific, however pleural fluid analysis demonstrates striking eosinophilia (10%-50%) and BAL fluid classically shows marked eosinophilia (25%-55%). Treatment includes supportive care, withdrawal of any eliciting medications, and glucocorticoid therapy. Most patients rapidly improve within 12-48 hours of initiation of corticosteroids. The prognosis for acute eosinophilic pneumonia is excellent with the vast majority of patients enjoying complete recovery. CONCLUSIONS: This case highlights the rare but important association between drug-induced eosinophilic pneumonia and extended-release injectable naltrexone. REFERENCE #1: Korpole PR, Al-Bacha S, Hamadeh S. A Case for Biopsy: Injectable Naltrexone-Induced Acute Eosinophilic Pneumonia. Cureus. 2020;12(9):e10221. Published 2020 Sep 3. doi:10.7759/cureus.10221 REFERENCE #2: Eosinophilic pneumonia induced by injectable naltrexone. Kim H, Ali M, Buch K. http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2014.189.1_MeetingAbstracts.A2283 Am J Respir Crit Care Med. 2014;189:2283. REFERENCE #3: Saved by the BAL: a case of acute eosinophilic pneumonia after methyl-naltrexone injection. Esposito A, Lau B. Chest. 2019;156:2210. DISCLOSURES: No relevant relationships by Kari McCoy, source=Web Response No relevant relationships by Caroline Mears, source=Web Response No relevant relationships by Xian Qiao, source=Web Response

National Trends in Telestroke Utilization in a US Commercial Platform Prior to the COVID-19 Pandemic

ObjectivesMost data on telestroke utilization come from single academic hub-and-spoke telestroke networks. Our objective was to describe characteristics of telestroke consultations among a national sample of telestroke sites on one of the most commonly used common vendor platforms, prior to the COVID-19 public health emergency. Materials and methodsA commercial telestroke vendor provided data on all telestroke consultations by two specialist provider groups from 2013-2019. Kendall's τ β nonparametric test was utilized to assess time trends. Generalized linear models were used to assess the association between hospital consult utilization and alteplase use adjusting for hospital characteristics. ResultsAmong 67,736 telestroke consultations to 132 spoke sites over the study period, most occurred in the emergency department (90%) and for stroke indications (final clinical diagnoses: TIA 13%, ischemic stroke 39%, hemorrhagic stroke 2%, stroke mimics 46%). Stroke severity was low (median NIHSS 2, IQR 0–6). Alteplase was recommended for 23% of ischemic stroke patients. From 2013 to 2019, times from ED arrival to NIHSS, CT scan, imaging review, consult, and alteplase administration all decreased (p<0.05 for all), while times from consult start to alteplase recommendation and bolus increased (p<0.01 for both). Transfer was recommended for 8% of ischemic stroke patients. Number of patients treated with alteplase per hospital increased with increasing number of consults and hospital size and was also associated with US region in unadjusted and adjusted analyses. Longer duration of hospital participation in the network was associated with shorter hospital median door-to-needle time for alteplase delivery (39 min shorter per year, p=0.04). ConclusionsAmong spoke sites using a commercial telestroke platform over a seven-year time horizon, times to consult start and alteplase bolus decreased over time. Similar to academic networks, duration of telestroke participation in this commercial network was associated with faster alteplase delivery, suggesting practice improves performance.

Compression depth measured by accelerometer vs. outcome in patients with out-of-hospital cardiac arrest

BackgroundAnalyses of data recorded by monitor-defibrillators that measure CPR depth with different methods show significant relationships between the process and outcome of CPR. Our objective was to evaluate whether chest compression depth was significantly associated with outcome based on accelerometer-recordings obtained with monitor-defibrillators from a single manufacturer, and to assess whether an accelerometer-based analysis corroborated evidence-based practice guidelines on performance of CPR. Methods and resultsWe included 5434 adult patients treated from seven US and Canadian cities between January 2007 and May 2015. These had mean (SD) age of 64.2 (17.2) years, mean compression depth of 45.9 (12.7) mm, ROSC sustained to ED arrival of 26%, and survival to hospital discharge of 8%. For survival to discharge, the adjusted odds ratios were 1.15 (95% CI, 0.86, 1.55) for cases within 2005 depth range (38–51 mm), and 1.17 (95% CI, 0.91, 1.50) for cases within 2010 depth range (>50 mm) compared to those with an average depth of <38 mm. The adjusted odds ratio of survival was 1.33 (95% CI, 1.01, 1.75) for cases within 2015 depth range (50 to 60 mm) for at least 60% of minutes. ConclusionsThis analysis of patients with OHCA demonstrated that increased chest compression depth measured by accelerometer is associated with better survival. It confirms that current evidence-based recommendations to compress within 50–60 mm are likely associated with greater survival than compressing to another depth.

Hospital complications among older adults: Better processes could reduce the risk of delirium

Using observational data and variation in hospital admissions across days of the week, we examined the association between ED boarding time and development of delirium within 72 hours of admission among patients aged 65+ years admitted to an inpatient neurology ward. We exploited a natural experiment created by potentially exogenous variation in boarding time across days of the week because of competition for the neurology floor beds. Using proportional hazard models adjusting for socio-demographic and clinical characteristics in a propensity score, we examined the time to delirium onset among 858 patients: 2/3 were admitted for stroke, with the remaining admitted for another acute neurologic event. Among all patients, 81.2% had at least one delirium risk factor in addition to age. All eligible patients received delirium prevention protocols upon admission to the floor and received at least one delirium screening event. While the clinical and social-demographic characteristics of admitted patients were comparable across days of the week, patients with ED arrival on Sunday or Tuesday were more likely to have had delayed floor admission (waiting time greater than 13 hours) and delirium (adjusted HR = 1.54, 95%CI:1.37-1.75). Delayed initiation of delirium prevention protocol appeared to be associated with greater risk of delirium within the initial 72 hours of a hospital admission.

The epidemiology of overtransfusion of red cells in trauma resuscitation patients in the context of a mature massive transfusion protocol

PurposePacked red blood cell (PRBC) transfusion remains an integral part of trauma resuscitation and an independent predictor of unfavourable outcomes. It is often administered urgently based on clinical judgement. These facts put trauma patients at high risk of potentially dangerous overtransfusion. We hypothesised that trauma patients are frequently overtransfused and overtransfusion is associated with worse outcomes.MethodsTrauma patients who received PRBCs within 24 h of admission were identified from the trauma registry during the period January 1 2011–December 31 2018. Overtransfusion was defined as haemoglobin concentration of greater than or equal to 110 g/L at 24 h post ED arrival (± 12 h). Demographics, injury severity, injury pattern, shock severity, blood gas values and outcomes were compared between overtransfused and non-overtransfused patients.ResultsFrom the 211 patients (mean age 45 years, 71% male, ISS 27, mortality 12%) who met inclusion criteria 27% (56/211) were overtransfused. Patients with a higher pre-hospital systolic blood pressure (112 vs 99 mmHg p < 0.01) and a higher initial haemoglobin concentration (132 vs 124 p = 0.02) were more likely to be overtransfused. Overtransfused patients received smaller volumes of packed red blood cells (5 vs 7 units p = 0.049), fresh frozen plasma (4 vs 6 units p < 0.01) and cryoprecipitate (6 vs 9 units p = 0.01) than non-overtransfused patients.ConclusionMore than a quarter of patients in our cohort were potentially given more blood products than required without obvious clinical consequences. There were no clinically relevant associations with overtransfusion.

Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study

BackgroundEarly hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality.MethodsA 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected.ResultsFour hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified.ConclusionsDespite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED.

Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial

ObjectiveTo compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress.MethodsWe conducted a parallel group, individual patient, non-blinded randomised controlled trial...

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BackgroundCOVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. Methodsin this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. Resultsof 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015). Conclusiona trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

Introduction of point-of-care ROTEM testing in the emergency department of an Australian level 1 trauma centre and its effect on blood product use.

To assess whether the introduction of point-of-care rotational thromboelastometry (ROTEM) analysis influences blood product transfusion and coagulation management in a modern Australian level 1 trauma centre. Retrospective blood transfusion data collection from all level 1 trauma patients with an Injury Severity Score (ISS) >12 presenting to the Royal Adelaide Hospital in 2016 and 2018. Evaluation of changes in blood product administration with the addition of point-of-care viscoelastic testing in the ED in 2018. A total of 774 patients were analysed with 380 in 2016 and 394 in 2018. Almost a quarter of all 2018 trauma patients (93/394) had ROTEM performed within 24 h of ED arrival, 42% of these having an ISS >25. There was a significant increase in the number of patients receiving cryoprecipitate following the introduction of ROTEM (P= 0.01). In those receiving cryoprecipitate, there was a significant reduction in subsequent platelet and fresh frozen plasma use (P< 0.001). Overall, there was a reduction in expenditure on red cells, platelets and fresh frozen plasma from 2016 to 2018. Point-of-care ROTEM was performed in a small proportion of patients, mainly those with a higher ISS. ROTEM introduction in the ED altered blood product transfusion practices for major trauma patients with an ISS >12, leading to a potentially safer transfusion strategy and cost savings for key blood products.

Abstract 3: Early Recanalization of Large Vessel Occlusions by tPA on the Mobile Stroke Unit

Introduction: The benefit of intravenous tPA in acute ischemic stroke patients with large vessel occlusions (LVOs) is limited but time dependent. We evaluated pre-hospital treatment with tPA on the Mobile Stroke Unit (MSU) to explore the recanalization rate in patients with LVOs and its effect on clinical improvement upon ED arrival. Methods: Prospectively derived data were analyzed from patients on the Houston MSU who were treated with tPA and had LVOs identified by hyperdense artery on MSU CT or arterial occlusion on MSU CTA. The primary outcome was early recanalization, categorized as resolution of LVO on repeat vascular imaging in the ED or on emergent angiography versus no recanalization. Secondary outcome was change in baseline NIHSS at 24 hours. Differences in NIHSS were evaluated using Wilcoxon rank sum test with continuity correction. Results: Seventy-one patients received tPA and had proximal LVOs both in the anterior and posterior circulation. Eleven had recanalization on CTA upon ED arrival (15.5%), while 7 had recanalization on emergent angiography (9.9%). The total early recanalization rate with tPA was 25.4%. Forty-seven patients with persistent LVOs on ED arrival (66.2%) underwent endovascular thrombectomy (EVT). Time from symptom onset (last known normal) to tPA bolus did not differ significantly between the early recanalization vs non-early recanalization groups (64.5 minutes [IQR 43.0-78.5] vs 64.0 minutes [52.5-92.0]; p = 0.41). Early recanalization resulted in greater improvement in baseline to ED arrival NIHSS (median NIHSS change 4.0 [0-11.8] vs 0 [0-3.5]; p = 0.01). There were no differences in ED arrival to 24 hour NIHSS between the early recanalization versus non-early recanalization groups irrespective of EVT. Conclusions: Recanalization by ED arrival occurs in 25% of LVO patients with tPA treatment on a MSU and was associated with early clinical improvement. Subsequent EVT did not “make up” for the clinical benefit of early recanalization.

Abstract 19: Prehospital Identification of Acute Ischemic Stroke is Associated With Faster and More Frequent Thrombolysis

Background: Functional outcomes are improved when AIS patients receive faster treatment. The first medical contact for many AIS patients is with emergency medical services (EMS) providers. We hypothesize that AIS treatment is faster when EMS providers suspect stroke. Methods: We performed a retrospective analysis of the Greater Cincinnati/Northern Kentucky Stroke Study, a comprehensive study of stroke patients in a large geographical area with 1.3 million inhabitants whose demographics are representative of the United States. We compared AIS patients age ≥18 years transported by EMS in 2015 with an EMS impression of “stroke” or “weakness/numbness” to those with other EMS impressions. Primary outcome was thrombolysis rate, and secondary outcomes were times from EMS scene arrival to ED arrival, CT, and treatment and times from ED arrival to CT and treatment. Chi-square and Mann-Whitney U-tests were used to compare treatment rates and times, respectively. Logistic regression (for rates) and median regression (for times) adjusted for NIHSS, GCS, age, sex, race, and prior stroke history. Results: Among 2,486 confirmed AIS patients from 1/1/2015-12/31/2015, 868 were transported by EMS, including 595 (69%) with EMS suspected stroke. Compared to EMS non-suspected strokes, patients with EMS suspected stroke patients were more likely to receive thrombolysis (18% vs 8%; OR 2.67, 95% CI 1.63-4.47) and had faster prehospital transport (30 vs 32 min, p=0.02), ED arrival to CT (27 vs 46 min, p&lt;0.01) and thrombolysis (64 vs 83 min, p=0.03), and EMS scene arrival to thrombolysis (91 vs 118 min, p=0.03) and EVT (164 vs 250 min, p=0.03). Findings were maintained in the adjusted models except for EMS arrival to EVT (Table). Conclusions: In a large population-based study, EMS stroke identification is associated with a higher rate of and faster thrombolysis. Efforts to increase accuracy of EMS stroke identification is likely to have significant clinical impact by shortening treatment times.

The impact of COVID-19 lockdown on infectious diseases epidemiology: The experience of a tertiary Italian Pediatric Emergency Department.

IntroductionThe aim of this study was to describe the rate and types of community-acquired respiratory infections observed in a pediatric ED during the SARS-CoV-2 related lockdown in Italy and to compare data with the same period of previous year.MethodsA retrospective analysis of medical charts of patients arrived at the ED of Gaslini Children's Hospital from 10th March 2020 to 30th April 2019 and the same frame of 2020 were performed. We compared two groups by demographics, duration of fever before ED admission, triage code, number of patients hospitalized after ED evaluation. We calculated proportion and incidence rate for airborne infections, fever, and urinary tract infections (UTI), appendicitis, and gastroenteritis for control.Results1362 children arrived at the ED during the lockdown compared to 5628 in the same period of 2019 (−75,8%). No difference was noticed (27.7% vs 28.4%) in the total amount of infectious episodes. A significant reduction in rate of incidence and proportion were observed for upper respiratory tract infections (21,4% vs 28%), otitis (2,6% vs 16,2%), streptococcal infections (0,5% vs 5,2%) and bronchiolitis (2,1% vs 5,7%). Conversely, FUO (27,8 vs 11,1%), infectious mononucleosis (2,6% vs 0,4%), UTI (7,4% vs 2,9%) and appendicitis (6,8% vs 1,1%) significantly increased. Median time from the onset of fever and arrival in ED was significantly lower in 2020 group.ConclusionOur results demonstrated a reduction in community-acquired respiratory infections during the lockdown for COVID-19. The increase in rate of FUO and febrile conditions, together with the short time from fever onset and ED visit could be related to the fear for a SARS-CoV-2 infection.