Emergency Department Vital Signs Research Articles

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services

BackgroundThe optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of...

PRECISION-TBI: a study protocol for a vanguard prospective cohort study to enhance understanding and management of moderate to severe traumatic brain injury in Australia

IntroductionTraumatic brain injury (TBI) is a heterogeneous condition in terms of pathophysiology and clinical course. Outcomes from moderate to severe TBI (msTBI) remain poor despite concerted research efforts. The heterogeneity...

Correlation Between Shock Index and Mortality in the Prehospital and Level 1 Rural Trauma Center Emergency Department Settings

Background: The shock index is a valid tool used to detect impending circulatory collapse in the pre-hospital setting. As validation of the shock index requires high sample sizes, the majority of retrospective studies have been performed at urban level 1 trauma centers. We hypothesized that the shock index would accurately predict mortality in a rural level 1 trauma center. Objective - Determine if the shock index continues to be a reliable predictive value in trauma patients for morbidity and mortality. Setting - This retrospective study was performed at a state-designated level 1 trauma center in Johnson City, Tennessee. Patients were excluded from the study if they were under the age of 18, not immediately transported to the trauma center or if insufficient data was available. The shock index was calculated as heart rate/systolic blood pressure. Both the prehospital and emergency department shock indexes were calculated, with the emergency department vital signs being the first upon arrival. Patients were divided into three categories: SI ≤ 0.7, 0.71-0.89, and ≥ 0.9. We assessed the relationship between SI, blood product usage, and outcome variables using Pearson correlation coefficients and logistic regression. Chi-square analysis was used to show the difference in mortality between the groups. Results - A higher shock index score after arrival to the emergency department experienced longer hospital, intensive care unit, and mechanical ventilation days, injury severity scores, packed red blood cells, plasma, platelets, and total blood product usage. Mortality was higher in the groups with an SI of ≥ 0.9 at the scene and arrival to the emergency department. Conclusion - Patients with a shock index > 0.71-0.89 in both prehospital and emergency departments had higher mortality rates and need for transfusion. The shock index continues to be a reliable predictive value in trauma patients for morbidity and mortality.

The effect of relative hypotension on 30-day mortality in older people receiving emergency care

Research has observed increased mortality among older people attending the emergency department (ED) who had systolic pressure > 7 mmHg lower than baseline primary care values. This study aimed to (1) assess feasibility of identifying this ‘relative hypotension’ using readily available ED data, (2) externally validate the 7 mmHg threshold, and (3) refine a threshold for clinically important relative hypotension. A single-centre retrospective cohort study linked year 2019 data for ED attendances by people aged over 64 to hospital discharge vital signs within the previous 18 months. Frailty and comorbidity scores were calculated. Previous discharge (‘baseline’) vital signs were subtracted from initial ED values to give individuals’ relative change. Cox regression analysis compared relative hypotension > 7 mmHg with mean time to mortality censored at 30 days. The relative hypotension threshold was refined using a fully adjusted risk tool formed of logistic regression models. Receiver operating characteristics were compared to NEWS2 models with and without incorporation of relative systolic. 5136 (16%) of 32,548 ED attendances were linkable with recent discharge vital signs. Relative hypotension > 7 mmHg was associated with increased 30-day mortality (HR 1.98; 95% CI 1.66–2.35). The adjusted risk tool (AUC: 0.69; sensitivity: 0.61; specificity: 0.68) estimated each 1 mmHg relative hypotension to increase 30-day mortality by 2% (OR 1.02; 95% CI 1.02–1.02). 30-day mortality prediction was marginally better with NEWS2 (AUC: 0.73; sensitivity: 0.59; specificity: 0.78) and NEWS2 + relative systolic (AUC: 0.74; sensitivity: 0.63; specificity: 0.75). Comparison of ED vital signs with recent discharge observations was feasible for 16% individuals. The association of relative hypotension > 7 mmHg with 30-day mortality was externally validated. Indeed, any relative hypotension appeared to increase risk, but model characteristics were poor. These findings are limited to the context of older people with recent hospital admissions.

Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review

Introduction Resuscitative thoracotomy (RT) is an emergent procedure to gain access to the thoracic cavity to control hemorrhage and other life-threatening injuries. Data predicting survival is variable. This review aims to highlight key predictors of survival and mortality following RT. Methods The EMBASE database was searched using the following terms: [exp. Thoracotomy] AND [Trauma.mp] AND [exp. Survival OR exp. Mortality]. The search was limited to full-text articles in the English language and publications released up to February 27, 2022. Reference lists of included articles were reviewed to identify other studies meeting inclusion criteria. Results Thirty-seven studies were included. Seventy-six outcome predictors were identified. Prehospital outcome predictors included prehospital vital signs, police transport, cardiopulmonary resuscitation, application of a cervical spine collar, and the number of total prehospital procedures performed. In-hospital variables associated with survival included traumatic cardiac arrest (TCA) in the emergency department (ED), initial ED vital signs and cardiac rhythm, Shock Index Pediatric Age-Adjusted score, location of RT, duration of RT, Focused Assessment with Sonography in Trauma findings, amount of blood products, and amount of administered fluids. Conclusions Our study highlights the disparity of data regarding prehospital outcome predictors for trauma patients requiring RT. Most studies focus on injury-specific and in-hospital variables and do not explicitly look at the TCA population. Further work is needed to better define specific variables implicated in enhanced survival across different care settings and to inform management guidelines within these clinical areas.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care.

Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care. Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected. There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049). Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child. Prognostic and Epidemiological; Level IV.

Development and Comparative Performance of Physiologic Monitoring Strategies in the Emergency Department

Accurate and timely documentation of vital signs affects all aspects of triage, diagnosis, and management. The adequacy of current patient monitoring practices and the potential to improve on them are poorly understood. To develop measures of fit between documented and actual patient vital signs throughout the visit, as determined from continuous physiologic monitoring, and to compare the performance of actual practice with alternative patient monitoring strategies. This cross-sectional study evaluated 25 751 adult visits to continuously monitored emergency department (ED) beds between August 1, 2020, and December 31, 2021. A series of monitoring strategies for the documentation of vital signs (heart rate [HR], respiratory rate [RR], oxygen saturation by pulse oximetry [Spo2], mean arterial pressure [MAP]) was developed and the strategies' ability to capture physiologic trends and vital sign abnormalities simulated. Strategies included equal spacing of charting events, charting at variable intervals depending on the last observed values, and discrete optimization of charting events. Coverage was defined as the proportion of monitor-derived vital sign measurements (at 1-minute resolution) that fall within the bounds of nursing-charted values over the course of an ED visit (HR ± 5 beats/min, RR ± 3 breaths/min, Spo2 ± 2%, and MAP ± 6 mm Hg). Capture was defined as the documentation of a vital sign abnormality detected by bedside monitor (tachycardia [HR >100 beats/min], bradycardia [HR <60 beats/min], hypotension [MAP <65 mm Hg], and hypoxia [Spo2 <95%]). Median patient age was 60 years (IQR, 43-75 years), and 13 329 visits (51.8%) were by women. Monitored visits had a median of 4 (IQR, 2-5) vital sign charting events per visit. Compared with actual practice, a simple rule, which observes vital signs more frequently if the last observation fell outside the bounds of the previous values, and using the same number of observations as actual practice, produced relative coverage improvements of 31.5% (95% CI, 30.5%-32.5%) for HR, 31.0% (95% CI, 30.0%-32.0%) for MAP, 16.8% (95% CI, 16.0%-17.6%) for RR, and 7.8% (95% CI, 7.3%-8.3%) for Spo2. The same strategy improved capture of abnormalities by 38.9% (95% CI, 26.8%-52.2%) for tachycardia, 38.1% (95% CI, 29.0%-47.9%) for bradycardia, 39.0% (95% CI, 24.2%-55.7%) for hypotension, and 123.1% (95% CI, 110.7%-136.3%) for hypoxia. Analysis of optimal coverage suggested an additional scope for improvement through more sophisticated strategies. In this cross-sectional study, actual documentation of ED vital signs was variable and incomplete, missing important trends and abnormalities. Alternative monitoring strategies may improve on current practice without increasing the overall frequency of patient monitoring.

Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation

Objective Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission. Methods We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children’s hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for “asthma,” “bronchospasm,” or “wheezing.” Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission. Results Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1–22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84–0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%–46%). Conclusions A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.

64-Year-Old Woman With Aphasia and Troponin Elevation

64-Year-Old Woman With Aphasia and Troponin Elevation

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

69-Year-Old Man With Dysuria and Right Lower Abdominal Pain

Time to OR for patients with abdominal gunshot wounds: A potential process measure to assess the quality of trauma care?

Abdominal gunshot wounds (GSWs) require rapid assessment and operative intervention to reduce the risk of death and complications. We sought to determine if time to the operating room (OR) might be a useful process measure for the assessment of trauma care quality. We evaluated the facility benchmark time to OR for patients with serious injury and whether this was associated with lower rates of complications and mortality. We evaluated time to OR for adult patients with an abdominal GSW presenting in shock to American College of Surgeons Trauma Quality Improvement Program centers from 2015 to 2020. We calculated the 75th percentile time to the OR for each center and characterized centers as average, slow, or fast. We compared patient and facility characteristics across outlier status, as well as risk-adjusted complications and mortality using hierarchical multivariable logistic regression models. There were 4,027 patients in 230 centers that met the inclusion criteria. Mortality was 28%. There were 61 (27%) fast and 52 (23%) slow centers. The median time for slow centers was 83 minutes (68-94 minutes) compared with fast centers, 35 minutes (32-38 minutes). Injury Severity Score and emergency department vital signs were similar across centers. Fast hospitals had higher total case volumes, more cases per surgeon, and were more likely to be Level I centers. Patients cared for in these centers had similar risk-adjusted rates of complications and mortality. Time to OR for patients with abdominal GSWs and shock might be a useful process measure to evaluate rapid decision making and OR access. Surgeon and center experience as measured by annual case volumes, coupled with a rapid surgical response required through Level I trauma center standards might be contributory. There was no association between outlier status and complications or mortality suggesting other factors apart from time to the OR are of greater significance. Therapeutic/care management, Level IV.

Can we predict which COVID-19 patients will need transfer to intensive care within 24 hours of floor admission?

BackgroundPatients with COVID‐19 can present to the emergency department (ED) at any point during the spectrum of illness, making it difficult to predict what level of care the patient will ultimately require. Admission to a ward bed, which is subsequently upgraded within hours to an intensive care unit (ICU) bed, represents an inability to appropriately predict the patient's course of illness. Predicting which patients will require ICU care within 24 hours would allow admissions to be managed more appropriately.MethodsThis was a retrospective study of adults admitted to a large health care system, including 14 hospitals across the state of Indiana. Included patients were aged ≥ 18 years, were admitted to the hospital from the ED, and had a positive polymerase chain reaction (PCR) test for COVID‐19. Patients directly admitted to the ICU or in whom the PCR test was obtained > 3 days after hospital admission were excluded. Extracted data points included demographics, comorbidities, ED vital signs, laboratory values, chest imaging results, and level of care on admission. The primary outcome was a combination of either death or transfer to ICU within 24 hours of admission to the hospital. Data analysis was performed by logistic regression modeling to determine a multivariable model of variables that could predict the primary outcome.ResultsOf the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45).ConclusionsAlthough our model did not perform well enough to stand alone as a decision guide, it highlights certain clinical features that are associated with increased risk of decompensation.

Trauma outcome predictor: An artificial intelligence interactive smartphone tool to predict outcomes in trauma patients.

Classic risk assessment tools often treat patients' risk factors as linear and additive. Clinical reality suggests that the presence of certain risk factors can alter the impact of other factors; in other words, risk modeling is not linear. We aimed to use artificial intelligence (AI) technology to design and validate a nonlinear risk calculator for trauma patients. A novel, interpretable AI technology called Optimal Classification Trees (OCTs) was used in an 80:20 derivation/validation split of the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database. Demographics, emergency department vital signs, comorbidities, and injury characteristics (e.g., severity, mechanism) of all blunt and penetrating trauma patients 18 years or older were used to develop, train then validate OCT algorithms to predict in-hospital mortality and complications (e.g., acute kidney injury, acute respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, sepsis). A smartphone application was created as the algorithm's interactive and user-friendly interface. Performance was measured using the c-statistic methodology. A total of 934,053 patients were included (747,249 derivation; 186,804 validation). The median age was 51 years, 37% were women, 90.5% had blunt trauma, and the median Injury Severity Score was 11. Comprehensive OCT algorithms were developed for blunt and penetrating trauma, and the interactive smartphone application, Trauma Outcome Predictor (TOP) was created, where the answer to one question unfolds the subsequent one. Trauma Outcome Predictor accurately predicted mortality in penetrating injury (c-statistics: 0.95 derivation, 0.94 validation) and blunt injury (c-statistics: 0.89 derivation, 0.88 validation). The validation c-statistics for predicting complications ranged between 0.69 and 0.84. We suggest TOP as an AI-based, interpretable, accurate, and nonlinear risk calculator for predicting outcome in trauma patients. Trauma Outcome Predictor can prove useful for bedside counseling of critically injured trauma patients and their families, and for benchmarking the quality of trauma care.

Longer Prehospital Time Decreases Reliability of Vital Signs in the Field: A Dual Center Study.

Field vital signs are integral in the American College of Surgeons (ASA) Committee on Trauma (COT) triage criteria for trauma team activation (TTA). Reliability of field vital signs in predicting first emergency department (ED) vital signs, however, may depend upon prehospital time. The study objective was to define the effect of prehospital time on correlation between field and first ED vital signs. All highest level TTAs at two Level I trauma centers (2008-2018) were screened. Exclusions were unrecorded prehospital vital signs and those dead on arrival. Demographics, prehospital time (scene time + transport time), injury data, and vital signs were collected. Differences between field and first ED vitals were determined using the paired Student's t test. Propensity score analysis, adjusting for age, sex, injury severity score (ISS), and mechanism of injury compared outcomes among patients with ISS ≥16. Multivariate linear regression determined impact of prehospital time on vital sign differences between field and ED among propensity-matched patients. After exclusions, 21499 patients remained. Mean prehospital time was 32 vs. 41minutes (P < .001). On propensity score analysis, longer prehospital time was associated with significantly greater differences in systolic blood pressure (SBP) (P < .001), pulse pressure (PP) (P = .003), and Glasgow Coma Scale (GCS) (P < .001). On multivariate analysis, linear regression that demonstrated longer prehospital time was associated with greater differences in SBP, heart rate (HR), and PP (P < .001). Field vital signs are less likely to reflect initial ED vital signs when prehospital times are longer. Given the reliance of trauma triage criteria on prehospital vital signs, medical providers must be cognizant of this pitfall during the prehospital assessment of trauma patients.

Optimal Prospective Predictors of Mortality in Austere Environments

BackgroundProspective predictors of trauma-related outcomes have been validated to guide management in low-resource settings. The primary objective of this study was to determine the optimal prospective prediction method for mortality within combat and humanitarian trauma. Materials and methodsRetrospective review of the Department of Defense Trauma Registry from 2008 to 2016 was performed for adult patients. Areas under receiver operating characteristic curves (AUROCs) were calculated to assess the predictability of shock index (SI), reverse SI × Glasgow Coma Scale (rSIG), SI × Glasgow Coma Scale (SIG), Revised Trauma Score, and Trauma and Injury Severity Score (TRISS) on mortality at point of injury, arrival in emergency department (ED), and the difference in vital signs between those time points. ResultsA total of 22,218 patients were included. Overall, 97.1% were male, median age range 25-29 y, Injury Severity Score 9.4 ± 0.07, with predominantly penetrating injuries (58.1%), and mortality of 3.4%. ED vitals yielded higher predictability of mortality for all tests based on higher AUROCs. TRISS and rSIG demonstrated the highest AUROCs (0.955 and 0.923, respectively). The optimal cutoff value for rSIG was 14.1 (sensitivity 89% and specificity 87%). rSIG values <14.1 were significantly associated with mortality (P < 0.01; odds ratio = 5.901). ConclusionsInitial ED vital signs represented a better predictor of early mortality compared with point of injury vital signs for all predictive tools assessed. TRISS and rSIG proved to be most predictive of mortality. However, of the prospective tools assessed, rSIG may be optimal scoring tool because of its ease of calculation and its increased ability to predict mortality.

Shock Index as a Marker for Mortality Rates in Those Admitted to the Medical Intensive Care Unit from the Emergency Department.

ObjectiveShock index (SI) is defined as the heart rate divided by systolic blood pressure. Studies have shown a correlation between the shock index and mortality in trauma patients in prehospital settings and in the emergency department (ED). The objective of this study was to identify the utility of SI in predicting mortality in the medical intensive care unit (MICU) patients admitted from the ED and transfers from the floor to MICU. DesignWe performed a retrospective analysis of adult patients admitted to the MICU at our urban trauma hospital between January 2015 through August 2015 using ED vital signs to calculate the shock index and identify inpatient deaths. Similar data were examined for inpatient transfers to the MICU.ResultsNine hundred and fifty patients were included in the study; 743 had an SI ≤ 0.99 with a mortality rate of 15.9%. Two hundred and seven patients had a SI ≥ 1.00 with a mortality rate of 22.7%. A higher SI was significant for mortality. There was no statistical significance in SI and mortality rate for patients transferred from the medical floor to the ICU.ConclusionsPatients with an SI ≥ 1.00 from initial ED vital signs correlated with a higher mortality rate. In patients transferred from the floor to MICU, SI ≥ 1.00 did not correlate with a higher mortality rate.

Prehospital Vital Signs Accurately Predict Initial Emergency Department Vital Signs.

Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals. The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well. Patients meeting criteria for highest levels of TTA at a Level I trauma center (2008-2018) were included. Those with absent or missing prehospital vital signs were excluded. Demographics, injury data, and prehospital and first ED vital signs were abstracted. Prehospital and initial ED vital signs were compared using Bland-Altman intraclass correlation coefficients (ICC) with good agreement as >0.60; fair as 0.40-0.60; and poor as <0.40). After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15). Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.

Characteristics and Outcomes of Pediatric Septic Patients With Cancer: A Retrospective Cohort Study.

Pediatric oncology patients may be at a higher risk of complications and mortality from sepsis compared with their nononcology counterpart. The aim of this study is to compare characteristics, treatment, and sepsis-related mortality between oncology and nononcology patients presenting to the emergency department (ED). This is a retrospective single-center cohort study including patients <18years old with a diagnosis of sepsis, severe sepsis, septic shock, or bacteremia presenting to an academic ED between January 2009 and January 2015. A total of 158 patients were included with 53.8% having an underlying malignancy. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED vital signs, resuscitation parameters, laboratory work, infection site, general practitioner unit, intensive care unit length of stay, and hospital length of stay. Oncology patients had a higher in-hospital mortality (5.9% vs. 2.7%), however, it did not meet statistical significance (p=0.45). On presentation, oncology patients had a lower respiratory rate (24.33±9.48 vs. 27.45±7.88; p=0.04). There was a significant increase in the white blood count in oncology patients (4.011±4.965 vs. 17.092±12.806; p<0.001) with this cohort receiving more intravenous fluids. In the first 6hours (33.0±27.7mL/kg vs. 24.9±16.1mL/kg; p=0.029) as well as having a higher percentage of vasopressor administration (15.3% vs. 1.4%; p=0.002). Antibiotics were initiated at an earlier stage in the oncology cohort (1.25±1.95 vs. 3.33±1.97hours; p<0.0001). Cancer-free patients had a significantly higher rate of lung infections compared with cancer patients (68.5% vs. 32.9%; p<0.0001). In terms of infection characteristics, cancer patients had a higher percentage of bacteremia (27.1% vs. 4.1%; p<0.001). There was no statistical significance regarding mortality between the 2 cohorts. Pediatric cancer patients were found to have a higher incidence of bacteremia and received more aggressive treatment.

Operative spinal trauma: Thromboprophylaxis with low molecular weight heparin or a direct oral anticoagulant

Unlabelled Box BackgroundSpinal trauma patients are at high risk for venous thromboembolism (VTE). ObjectiveTo compare the impacts of direct oral anticoagulants (DOACs) and low molecular weight heparin (LMWH) as thromboprophylactic agents on outcomes in operative spinal trauma patients. MethodsA 2‐year (2015‐2016) retrospective cohort analysis of such patients (spine Abbreviated Injury Scale [AIS] ≥ 3 and other AIS < 3) who received LMWH or DOACs was performed. Propensity score matching (1:2 ratio) followed stratification into two groups. Outcomes included rates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE), packed red blood cell (pRBC) transfusion, operative interventions for spinal cord decompression, and mortality. ResultsOf 6036 patients, 810 (270 receiving DOACs; 540 receiving LMWH) were matched. The mean age was 62 ± 15 years, 58% were male, and the median Injury Severity Score was 12 (10‐18). Matched groups were similar in demographics, injury parameters, emergency department vital signs, hospital stay, rates of inferior vena cava filter placement, and timing of initiation of thromboprophylaxis. The overall rate of in‐hospital DVT was 5.6%, the overall rate of in‐hospital PE was 1.6%, and the mortality rate was 2.5%. DOAC patients were less likely to develop DVT (1.8% vs 7.4%) and PE (0.3% vs 2.1%). There were no differences in postprophylaxis pRBC transfusion requirements, postprophylaxis decompressive procedures on the spinal cord, or mortality. ConclusionIn operative spinal trauma patients, thromboprophylaxis with DOACs appears to be associated with lower rates of DVT and PE. Further prospective clinical trials should evaluate the role of DOACs in preventing VTE events in spinal trauma patients.