Emergency Department Arrival Research Articles

Abstract WP60: On vs. Off-Hours Arrival to Groin Time: Identifying Gaps in a Comprehensive Stroke Center

Introduction: Timeliness of treatment for patients with acute ischemic stroke (AIS) directly correlates with outcomes. The most current AHA guidelines standard of care for patients having a large vessel occlusion (LVO) stroke is endovascular mechanical thrombectomy (MT). Earlier treatment is associated with better outcomes at 90 days. Parallel processing is paramount when executing an expedited transition from the emergency department (ED) to the MT suite. At a large academic comprehensive stroke center (CSC), as we receive a high volume of direct ED cases, we examined whether there was a difference in daytime vs. off-hour LVO cases. Methods: The MT database maintained by the CSC was queried for all cases from July 2022- July 2023. Inclusion criteria included all AIS with LVO and receiving MT that were transported by EMS directly to the CSC ED. Data was further stratified by time of day and day of the week. Cases were designated as day if they arrived Monday through Friday between 7am-5pm. Cases were considered night/weekend if they arrived 5pm-7am or anytime Saturday or Sunday. Times between groups were compared with t-test. Results: There were a total of 37 cases in the day group and 43 cases in the night/weekend group. Patients arriving during the day had a median arrival-to-groin time of 89 minutes and a mean of 93 minutes. The night/weekend group had a median of 116 minutes and a mean of 125 minutes, and the difference was statistically significant (p=0.0009). Upon further analysis, mean ED arrival to suite time was significantly longer for night/weekends, 105 vs. 76 minutes, p=0.008, but mean suite to groin puncture time was not significantly different, 18 vs. 16 minutes, p=0.24. Conclusion: There is a statistically significant difference in arrival to suite/groin times between the day and night/weekend groups, therefore putting patients with LVO arriving off hours at higher risk for poor outcomes. Historically some cardiac cath labs have utilized nursing bridge teams to help with parallel processing, and we theorize that using such a team to facilitate preparation of the patient and suite, we can reduce treatment times for off-hour’s ED MT cases and potentially improve outcomes.

Abstract WP87: To Walk-In or Not to Walk-In: Effects of ED Mode of Arrival on Acute Stroke Treatment and Hospitalization Outcomes in a Large Integrated Healthcare System

Background: Prior studies reported that only half of stroke patients arrived at emergency departments (ED) via emergency medical services (EMS). We sought to assess predictors of ED mode of arrival and its effects on acute stroke care and inpatient outcomes in a large racial-ethnically diverse cohort. Methods: In 2016, we launched a system-wide standardized telestroke program for 21 certified stroke centers. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. This study cohort included non-cancelled stroke alerts seen by Telestroke in 2021. Assessment included demographics, ED arrival mode , initial NIH Stroke Scale (NIHSS), neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, hospital length of stay and discharge disposition. Clustered logistic regression was used to evaluate ED arrival mode’s effects on short-term outcomes. Results: Of the 7744 stroke alerts seen by Telestroke in 2021, 3264 (42.2%) were non-canceled. Among these, 2014 (61.7%) were in the early window (0-4.5 hours from last seen well). More of those arriving in the early window came via EMS compared to those seen in the extended window [1625 (80.7%) versus 729 (58.3%) respectively]. Among non-canceled ED stroke alerts, compared to patients who arrived via EMS, walk-in patients were younger, more Hispanic, had lower initial NIHSS scores, longer times for ED to contact Telestroke, slower DTN times, but less mortality [Table]. In multivariate analysis, walk-in patients were less likely to have a DTN time within 30 minutes (OR=0.37, 95% CI 0.25-0.34; p=<0.001). Conclusions: In our cohort, there were several differences between walk-in patients and those who arrived via EMS. Further research is needed to understand these differences, the reasons for choosing walk-in, and whether ED mode of arrival affects clinical outcomes.

Abstract NS9: Nurse-Led Quality Improvement Initiative: Advancing Stroke Awareness in Communities Experiencing Racial and Ethnic Disparities

Background and Purpose: As a Joint Commission Comprehensive Stroke Center, the provision of community education is a priority goal of our program. The majority of our existing community education program takes place in locations where we receive requests to provide these sessions. Analysis of our Get With the Guidelines (GWTG) data reveals gaps in early arrival to the hospital and Emergency Medical Service (EMS) utilization among African American and Hispanic populations. Providing educational resources within these populations may help to close these gaps and foster trust in the healthcare system. The aim of this proposed nurse-led quality improvement project is to improve hospital arrival times of African American and Hispanic stroke patients living in zip codes where GWTG data have identified gaps, through provision of targeted community education. Methods: The top zip codes associated with our target outcomes for improvement will be identified using GWTG pre-data from 2022 and 2023. We will partner with our Community Outreach department. We will identify educational venues and stakeholders among African American and Hispanic populations in these zip codes. We will provide education tailored to our identified populations including early recognition of stroke signs and symptoms, activation of EMS, stroke risk factors, and opportunities for treatment. Post implementation, GWTG data will be reviewed for any changes. Results: Using GWTG data, arrival mode, last known well time, and symptom discovery time to Emergency Department arrival as it pertains to zip codes, race and ethnicity will be reviewed and analyzed. The target zip codes’ data will be compared pre- versus post-implementation of community education efforts. Discussion: Through community education and partnership with the Community Outreach department we hope to improve timeliness of arrival to hospital among disproportionately affected racial minorities in our community for early stroke evaluation and treatment consideration.

Timing to First Whole Blood Transfusion and Survival Following Severe Hemorrhage in Trauma Patients

Civilian trauma centers have revived interest in whole-blood (WB) resuscitation for patients with life-threatening bleeding. However, there remains insufficient evidence that the timing of WB transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome. To evaluate whether earlier timing of first WB transfusion is associated with improved survival at 24 hours and 30 days for adult trauma patients presenting with severe hemorrhage. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program databank from January 1, 2019, to December 31, 2020, for adult patients presenting to US and Canadian adult civilian level 1 and 2 trauma centers with systolic blood pressure less than 90 mm Hg, with shock index greater than 1, and requiring MTP who received a WB transfusion within the first 24 hours of emergency department (ED) arrival. Patients with burns, prehospital cardiac arrest, deaths within 1 hour of ED arrival, and interfacility transfers were excluded. Data were analyzed from January 3 to October 2, 2023. Patients who received WB as an adjunct to MTP (earlier) compared with patients who had yet to receive WB as part of MTP (later) at any given time point within 24 hours of ED arrival. Primary outcomes were survival at 24 hours and 30 days. A total of 1394 patients met the inclusion criteria (1155 male [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included profoundly injured patients (median Injury Severity Score, 27 [IQR, 17-35]). A survival curve demonstrated a difference in survival within 1 hour of ED presentation and WB transfusion. Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with improved survival at 24 hours (adjusted hazard ratio, 0.40; 95% CI, 0.22-0.73; P = .003). Similarly, the survival benefit of earlier WB transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < .001). In this cohort study, receipt of a WB transfusion earlier at any time point within the first 24 hours of ED arrival was associated with improved survival in patients presenting with severe hemorrhage. The survival benefit was noted shortly after transfusion. The findings of this study are clinically important as the earlier timing of WB administration may offer a survival advantage in actively hemorrhaging patients requiring MTP.

Incidence, severity, and clinical characteristics of lower respiratory tract infections in children before and after the coronavirus disease 2019 lockdown: a Dutch single-center study

Purpose: Coronavirus disease 2019 (COVID-19) public health measures reduced the incidence of pediatric lower respiratory tract infections (LRTIs) in 2020. An inter-seasonal surge in the LRTI has occurred after relaxation of restrictions. We aimed to compare characteristics and disease severity of children with LRTI before, during, and after COVID-19 lockdown. Methods: All LRTI-related visits to emergency department (ED) of a large pediatric hospital in the Netherlands between 2019 and 2021 were included. Variables were compared between 2019 and 2020, and between 2019 and 2021, respectively. The variables included demographic characteristics, condition upon ED arrival, diagnosis, applied treatment, and follow-up.Results: In 2019, 2020, and 2021, numbers of the visits were 573, 280, and 519, respectively, comprising the study population (n = 1,372). In 2020, the patients were older, and showed higher frequencies of preterm birth history, co-occurring symptoms of obstructive lung disease, and salbutamol therapy in the ED, than in 2019. In 2021, the patients were younger, showed higher frequencies of desaturation, bronchiolitis, co-occurring symptoms of obstructive lung disease, salbutamol therapy, and hospitalization, and showed lower frequencies of respiratory ED visits or hospitalization in the past year, and antibiotic therapy. During hospitalization in 2020, the patients were older, and showed shorter duration of oxygen support and length of hospital stay, as well as lower frequencies of nasogastric tube insertion, compared to 2019. In 2021, compared to 2019, the patients showed a higher frequency of bronchiolitis and lower frequencies of underlying medical conditions and antibiotic therapy. Conclusion: The children presenting with LRTIs in 2021 seem to have had a more severe clinical phenotype, possibly explained by immunity debt after the COVID-19 lockdown, stricter referral policy, or changes in healthcare-seeking behavior. Future research is needed to evaluate the long-term consequences of growing up during the lockdown.

Managing Pediatric Asthma Exacerbations: The Role of Timely Systemic Corticosteroid Administration in Emergency Care Settings-A Multicentric Retrospective Study.

Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration. This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included. 205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration. Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.

Sepsis Prediction at Emergency Department Triage Using Natural Language Processing: Retrospective Cohort Study.

Despite its high lethality, sepsis can be difficult to detect on initial presentation to the emergency department (ED). Machine learning-based tools may provide avenues for earlier detection and lifesaving intervention. The study aimed to predict sepsis at the time of ED triage using natural language processing of nursing triage notes and available clinical data. We constructed a retrospective cohort of all 1,234,434 consecutive ED encounters in 2015-2021 from 4 separate clinically heterogeneous academically affiliated EDs. After exclusion criteria were applied, the final cohort included 1,059,386 adult ED encounters. The primary outcome criteria for sepsis were presumed severe infection and acute organ dysfunction. After vectorization and dimensional reduction of triage notes and clinical data available at triage, a decision tree-based ensemble (time-of-triage) model was trained to predict sepsis using the training subset (n=950,921). A separate (comprehensive) model was trained using these data and laboratory data, as it became available at 1-hour intervals, after triage. Model performances were evaluated using the test (n=108,465) subset. Sepsis occurred in 35,318 encounters (incidence 3.45%). For sepsis prediction at the time of patient triage, using the primary definition, the area under the receiver operating characteristic curve (AUC) and macro F1-score for sepsis were 0.94 and 0.61, respectively. Sensitivity, specificity, and false positive rate were 0.87, 0.85, and 0.15, respectively. The time-of-triage model accurately predicted sepsis in 76% (1635/2150) of sepsis cases where sepsis screening was not initiated at triage and 97.5% (1630/1671) of cases where sepsis screening was initiated at triage. Positive and negative predictive values were 0.18 and 0.99, respectively. For sepsis prediction using laboratory data available each hour after ED arrival, the AUC peaked to 0.97 at 12 hours. Similar results were obtained when stratifying by hospital and when Centers for Disease Control and Prevention hospital toolkit for adult sepsis surveillance criteria were used to define sepsis. Among septic cases, sepsis was predicted in 36.1% (1375/3814), 49.9% (1902/3814), and 68.3% (2604/3814) of encounters, respectively, at 3, 2, and 1 hours prior to the first intravenous antibiotic order or where antibiotics where not ordered within the first 12 hours. Sepsis can accurately be predicted at ED presentation using nursing triage notes and clinical information available at the time of triage. This indicates that machine learning can facilitate timely and reliable alerting for intervention. Free-text data can improve the performance of predictive modeling at the time of triage and throughout the ED course.

Utility of emergency department triage tools in predicting the need for intensive respiratory or vasopressor support in adult patients with COVID-19

BackgroundSerum and radiological parameters used to predict prognosis in COVID patients are not feasible in the Emergency Department. Due to its damaging effect on multiple organs and lungs, scores used to assess multiorgan damage and pneumonia such as Pandemic Medical Early Warning Score (PMEWS), National Early Warning Score 2 (NEWS2), WHO score, quick Sequential Organ Failure Assessment (qSOFA), and DS-CRB 65 can be used to triage patients in the Emergency Department. They can be used to predict patients with the highest risk of seven-day mortality and need for intensive respiratory or vasopressor support (IRVS). PurposeThe primary purpose was to find the score with the highest AUC in predicting IRVS and mortality at seven days. Additional objective was to find out any independent factors associated with IRVS and mortality. MethodsThe data of adult patients who presented to the Emergency Department (ED) between April 1, 2021 and June 30, 2021 were collected. The WHO score, CRB-65, DS-CRB 65, PMEWS, NEWS2, and qSOFA score were calculated for all patients. Statistical analysis was done and an ROC curve was calculated for all the tools for mortality and need for IRVS at seven days. Findings677 patients presented to the Emergency Department with COVID-19 during the period above. Presence of Diabetes Mellitus (p = 0.001), Hypertension (p = 0.001), and chronic kidney disease(CKD) (p = 0.04) was significantly associated with need for IRVS. Age, duration of symptoms, pulse rate, respiratory rate, room air saturation, mental status at admission, and time to IRVS need were identified as independent predictors of in-hospital mortality. The longer the time to IRVS need from ED arrival, the higher the likelihood of mortality. PMEWS (0.830) had the highest AUC, followed by NEWS2 (0.805). A PMEWS cut-off of 6.5 was 74.2% sensitive and 78.3% specific in predicting the need for IRVS. ROC analysis to predict 7-day mortality showed that PMEWS had an AUC of 0.802 (0.766–0.839). QSOFA performed poorly in predicting IRVS (AUC 0.645) and 7-day mortality (AUC 0.677). ConclusionPMEWS may be used for triaging patients presenting to the Emergency Department with COVID-19 and accurately predicts the need for IRVS and seven day mortality.

Head Trauma in Paediatric Patients Referring to a Spoke Hospital

Introduction: Head trauma (HT) is a leading cause of morbidity and mortality in children worldwide. The primary aim of this study was to describe patients presenting to our first-level Emergency Department (ED) following a HT. The secondary aims were to compare both the epidemiology and the management of paediatric patients with literature data, analyzing the appropriateness of management of children’s traumatic brain injuries according to the current guidelines.&#x0D; Methods: We conducted a retrospective review of medical records of patients aged &lt; 14 years who attended our first-level ED due to head trauma from July 1, 2021, and June 30, 2022. Clinical data, including age, gender, injury mechanism, location of trauma, time from traumatic event and ED arrival, symptoms at first evaluation, physical examination findings, radiological investigation results, medications administered in ED and prescribed at home, and outcome were collected and compared with data available in literature and current guidelines.&#x0D; Results: A total of 117 children aged &lt; 14 years who attended our first-level ED due to head trauma from July 1, 2021, and June 30, 2022, were analyzed. Most of them were males aged 1-3 years. Frontal bone was the commonest side of trauma (43% of HT). Only eleven patients (9%) had a brain CT scan and 4 of them showed pathological findings. None had signs of bleeding. Four of the patients were transferred to a HUB hospital, provided with a paediatric neurosurgery and more important none of them has developed neurological sequelae or death.&#x0D; Discussion: Our 1-year observation of HT showed how this is a frequent indication for ED referral, especially in young children. In our hands less than 10% of cases required CT scan that reported pathological cases in 4 patients only (3%). We can conclude that the reduction of ionizing radiation exposition can be obtained with skilled experienced physicians.

Transient Hematotoxicity After Emerald Horned Pitviper (Ophryacus smaragdinus) Envenomation: A Case Report

BackgroundA minority of snake envenomations in the United States involve non-native snakes. In this report, we describe what we believe is the first documented human envenoming from an emerald horned pitviper, Ophryacus smaragdinus. Case ReportA previously healthy 36-year-old woman was bitten on her left index finger by a captive emerald horned pitviper she was medicating at work. Swelling to the entire hand was present on emergency department arrival. She had no systemic symptoms and her initial laboratory studies were unremarkable. The affected limb was elevated. We administered five vials of Antivipmyn TRIⓇ (Bioclon), which specifically lists Ophryacus among the envenomations for which it is indicated. She developed pruritus and was treated with IV diphenhydramine and famotidine. Her swelling improved, but her repeat laboratory studies were notable for a platelet count of 102 K/µL and a fibrinogen level of 116 mg/dL. She declined additional antivenom because of the previous allergic reaction. She was admitted for further monitoring and pain control. Subsequent laboratory tests were better, but a small hemorrhagic bleb developed at the bite site. She was discharged the next day and followed up as an outpatient. Her swelling had resolved, her bleb had healed, and her laboratory studies continued to improve. Why Should an Emergency Physician Be Aware of This?Emergency physicians may be required to treat bites from non-native snakes. Many of these bites will warrant treatment with non–U.S. Food and Drug Administration–approved antivenoms. Consultation with a regional poison center or medical toxicologist may be necessary to procure the proper antivenom.

Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial

BackgroundThe appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels.MethodsWe performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups.ResultsOf the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury.ConclusionsOur results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.

Bilateral Hearing Loss after Carbon Monoxide Poisoning

Background: Carbon monoxide (CO) is an odorless, colorless, flammable gas that is formed by the incomplete combustion of fuels and binds to hemoglobin with 200 to 250 times greater affinity compared to oxygen. As a result, blood oxygen-carrying capacity is reduced when CO is bound to hemoglobin. Reversible and irreversible unilateral or bilateral hearing loss due to CO poisoning has rarely been reported. We present a case of an 18-year-old previously healthy male with bilateral hearing loss after severe CO poisoning. Case Report: An 18-year-old male with no past medical history presented to the emergency department (ED) after being found unconscious with emesis in his vehicle. He failed to respond to Naloxone. In the ED, he was obtunded with vital signs significant only for tachycardia of 115 bpm. Initial workup revealed leukocytosis (WBC 16.0 10*3/uL), hyperglycemia (glucose 195 mg/dl ) and high sensitivity troponin elevation (131 ng/L). Electrocardiogram revealed sinus tachycardia with an incomplete right bundle branch block. Head CT and urine drug immunoassay were negative. Several hours after ED arrival, it was reported that the vehicle had a known problem with the exhaust pipe. The patient remained unresponsive for several hours. Approximately 6 hours after ED arrival, a carboxyhemoglobin level was ordered and returned at 9.5%. A non-rebreather oxygen mask was applied and the patient began waking up shortly after. Prior to receiving the first session of hyperbaric oxygen therapy (HBO2), the patient complained of bilateral hearing loss with tinnitus. Three sessions of HBO2 were done in the first 24 hours. The patient remained with bilateral hearing loss and tinnitus with minimal improvement over the three day hospitalization. A 3 day course of dexamethasone 10 mg daily was given. Audiological testing was not performed prior to discharge. Six months after discharge, he continued to have tinnitus and hearing loss though endorsed improvement. His audiogram shows moderate hearing loss. Discussion: CO poisoning is a rare cause of hearing loss. Tinnitus with hearing loss is reported even less. The mechanism for hearing loss in the setting of CO poisoning has not been identified however it is believed to be due to tissue hypoxia. The pattern of hearing loss after acute or chronic CO poisoning is typically sensorineural and could be unilateral or bilateral, reversible or irreversible. HBO2 is commonly used to treat severe CO poisoning, and occasionally to treat idiopathic sensorineural hearing loss (ISNHL). However, HBO2 has not been described for the sole purpose of treating CO-associated hearing loss. Corticosteroids have been shown to prevent delayed neuropsychiatric sequelae after CO poisoning and to treat ISNHL, but no reported cases with CO hearing loss. Due to the potential benefits of these relatively benign interventions, the patient was treated with HBO2 and corticosteroids with improvement in symptoms. Conclusion: Hearing loss is a rare clinical manifestation of carbon monoxide poisoning with few reported cases in the literature. Resulting hearing loss may be unilateral or bilateral, and reversible or irreversible.

Emergency resuscitative thoracotomy in severe trauma: Analysis of the nation-wide registry data in Japan.

Emergency resuscitative thoracotomy is a potentially lifesaving procedure for patients with cardiac pulmonary arrest and profound circulatory failure resulting from a severe injury. However, survival rate post-emergency resuscitative thoracotomy shows considerable variation, with many studies constrained by limited sample sizes and ambiguous criteria for inclusion. Herein, we assessed the outcomes of emergency resuscitative thoracotomy and identified predictors of futility using Japan Trauma Data Bank data. Data of patients aged ≥18 years between 2004 and 2019 were analyzed. The primary outcome measure was survival at discharge. Descriptive statistics were used to compare the survivor and nonsurvivor groups. A multivariable logistic regression analysis was conducted to identify predictors of survival in patients undergoing emergency resuscitative thoracotomy while adjusting for confounding factors. Among patients who underwent emergency resuscitative thoracotomy, 684/5062 (13.5%) survived. Age <65 years (adjusted odds ratio, 1.351; 95% confidence interval, 1.130-1.615; p < 0.001), absence of cardiac pulmonary arrest on emergency department arrival (adjusted odds ratio, 1.694; 95% confidence interval, 1.280-2.243; p < 0.01), Injury Severity Score <16 (adjusted odds ratio, 2.195; 95% confidence interval, 1.611-2.992; p < 0.01), and penetrating injury (adjusted odds ratio, 1.834; 95% confidence interval, 1.384-2.431; p < 0.01) were identified as factors associated with survival at discharge. The survival rate for emergency resuscitative thoracotomy in Japan stands at approximately 13.5%. Factors contributing to survival include younger age, absence of cardiopulmonary arrest at emergency department arrival, lack of severe trauma, and sustaining penetrating injuries.

Time Pattern of Presentation of Victims of High-Speed Passenger Ferry Mass Casualty Incidents to the Emergency Department.

Mass Casualty Incidents (MCIs) involving high-speed passenger ferries (HSPFs) may result in the dual-wave phenomenon, in which the emergency department (ED) is overwhelmed by an initial wave of minor injuries, followed by a second wave of more seriously injured victims. This study aimed to characterize the time pattern of ED presentation of victims in such accidents in Hong Kong. All HSPF MCIs from 2005 to 2015 were reviewed retrospectively, with the time interval from accident to ED registration determined for each victim. Multivariable linear regression was used to identify independent factors associated with the time of ED presentation after the accidents. Eight MCIs involving 492 victims were identified. Victims with an Injury Severity Score (ISS) ≥ 9 had a significantly shorter median time interval compared to those with minor injuries. An ISS ≥ 9 and evacuation by emergency service vessels were associated with a shorter delay in ED arrival, whereas ship sinking, accident at nighttime, and a longer linear distance between the accident and receiving ED were associated with a longer delay. The dual-wave phenomenon was not present in HSPF MCIs. Early communication is the key to ensure early resource mobilisation and a well-timed response.

The role of test results in the emergency department in the evaluation of major torso injury patients

We studied the role of laboratory tests in the emergency department (ED) for the prediction of outcomes in major torso injury patients. We hypothesized that the laboratory test results in the ED could predict worse outcomes and be complement of the TRISS (trauma and injury severity score) which serves a popular prediction model for trauma patients. Patients with major torso trauma who were sent to a level-I trauma center between January 2016 and December 2020 were retrospectively studied. Demographic information, TRISS, and laboratory data (glucose, lactate, base deficit (BD)) were collected and analyzed. The early death (death within 24 hours from the ED arrival) and the long intensive care unit (ICU) length of stay (LOS) (over seven days) were defined as the primary and secondary outcomes. A prediction model that integrated TRISS and the laboratory test results was created and evaluated by using the receiver operating characteristic (ROC) curve with the area under the curve (AUC). In total, 827 patients were studied. The glucose (255.2 ± 109.9 vs. 192.1 ± 77.0, p &lt; 0.001) and lactate (77.2 ± 43.4 vs. 39.2 ± 26.4, p &lt; 0.001) levels were significantly higher in patients who died early. The performance of glucose, lactate and BD in identifying those major torso trauma patients who would die early demonstrated acceptable discrimination (glucose: AUC = 0.687; lactate: AUC = 0.778; BD: AUC = 0.734). Furthermore, a model that integrated the TRISS and laboratory tests showed calibration of AUC = 0.863. Moreover, the levels of BD and glucose were also independent factors of long ICU LOS. In conclusion, checking lactate, BD and blood glucose is recommended in the evaluation of major torso trauma patients. Biochemical markers are beneficial in predicting worse outcomes for patients with major torso trauma and can complement the TRISS for these patients.

Factors associated with definitive observation unit care in patients with non-traumatic epistaxis: a retrospective observational study

Epistaxis is one of the common causes of emergency department (ED) visits. However, most cases are not severe and undergo an unnecessary medical evaluation, especially in non-traumatic epistaxis. This study investigated how many patients require a definite observational unit (DOU) and what factors are associated with DOU among non-traumatic epistaxis patients. This retrospective observational study included 1197 non-traumatic epistaxis patients who visited the ED from January 2016 to December 2020. Multiple logistic regression analysis was performed to evaluate the association between risk factors and DOU care. In addition, the receiver operating characteristic (ROC) curve for predicting DOU care was analyzed to estimate the diagnostic ability of risk factors. A total number of 1122 patients with non-traumatic epistaxis were included in the final analysis. Among them, 41 (3.65%) patients needed DOU care. Male sex (odds ratio (OR) = 3.606, p = 0.003), hypertension (OR = 2.362, p = 0.020), inter-hospital transfer (OR = 2.358, p = 0.039), verbal mental status (OR = 29.436, p = 0.035), hemoglobin (Hb) level (OR = 0.724, p &lt; 0.001), revisit after initial discharge for epistaxis (OR = 8.813, p &lt; 0.001), and delayed ED arrival (≥180 min) (OR = 2.451, p = 0.030) were significant factors for DOU care. In addition, the area under the curve of the multiple logistic regression model for predicting DOU care was 0.870. Among the patients who visited ED due to non-traumatic epistaxis, only 3.65% of patients required DOU care. Male sex, mental status, Hb level, ED revisit after initial discharge, inter-hospital transfer and delayed ED arrival (&gt;180 min) were associated with DOU care. These findings will help to triage epistaxis patients before they visit the ED.

Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. ObjectiveTo investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. MethodsThis single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). ResultsThe rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). ConclusionsFluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.

Early Discharge versus 6-hour Observation in Mild Traumatic Brain Injury with Normal Brain CT Scan; a Comparative Pilot study of Outcomes.

Early discharge from the emergency department (ED) or a 6-hour observation in the ED are two methods for management of patients with mild traumatic brain injury (mTBI) with normal brain computed tomography (CT) scan. This study aimed to compare the outcomes of the two management options. This study is a single-center, open-label, pilot randomized case control study conducted in the ED of Ramathibodi Hospital from June 2022 to September 2023. Eligible participants included all individuals with mTBI who had negative findings on Brain CT scans. They were randomly assigned to either the early ED discharge or 6-hour ED observation group and compared regarding the outcomes (rate of 48-hour ED revisits; occurrence of post-concussion syndrome (PCS) 1 day, 1 month, and 3 months after the initial injury; and 3-month mortality). 122 patients with the mean age of 74.62 ± 14.96 (range: 25-99) years were consecutively enrolled (57.37% female). No significant differences were observed between the early discharge and observation groups regarding the severity of TBI (p=0.853), age (p=0.334), gender (p=0.588), triage level (p=0.456), Glasgow Coma Scale (GCS) score (p=0.806), comorbidities (p=0.768), medication usage (p=0.548), mechanism of injury (p=0.920), indication for brain CT scan (p=0.593), time from TBI onset to ED arrival (p=0.886), and time from ED triage to brain CT scan (p=0.333). Within 48 hours after randomization, the incidence of revisits was similar between the two groups (1.57% vs. 3.23%; p = 1.000). There were no statistically significant differences in the incidence of PCS between the early discharge and observation groups at 1 day (33.90% vs. 35.48%, p = 0.503), at 1 month (12.07% vs. 13.11%, p = 0.542), and at 3 months (1.92% vs. 5.56%, p = 0.323) after randomization. After a three-month follow-up period, four patients in the early discharge group, had expired (none of the deaths were associated with TBI). It seems that, in mTBI patients with normal initial brain CT scan and the absence of other injuries or neurological abnormalities, early discharge from the ED without requiring observation could be considered safe.

Clinical and Echocardiographic Predictors for the Presence of Late Gadolinium Enhancement on Cardiac Magnetic Resonance Imaging in Patients with Carbon Monoxide Poisoning.

Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) reflects the burden of myocardial damage in carbon monoxide (CO) poisoning. This study aimed to identify the clinical and echocardiographic parameters that can predict myocardial LGE on CMRI in CO poisoning. This prospective observational study included patients who presented with acute CO poisoning and elevated troponin I and underwent echocardiography and CMRI to identify myocardial damage at a tertiary university hospital between August 2017 and May 2019 and August 2020 and July 2022. Based on the CMRI findings, participants were categorized into LGE and non-LGE groups. The median age of the 155 patients was 51.0 years, and 98 (63.2%) were males. Median times from emergency department arrival to either CMRI or echocardiography were 3.0 days each. The LGE group included 99 (63.9%) patients with LGE positivity on CMRIs. Time from rescue to hyperbaric oxygen therapy >4 h (odds ratio (OR): 3.31, 95% confidence interval (CI): 1.28-8.56, p = 0.01); serum lactate levels >2 mmol/L (OR: 2.62, 95% CI: 1.20-5.73, p = 0.02); and left ventricular global longitudinal strain >-16% (OR: 2.95, 95% CI: 1.35-6.47, p = 0.007) were significant predictors of LGE positivity. The area under the curve of these predictors was 0.711. Our prediction model, which combines the clinical parameters with left ventricular global longitudinal strain, may be helpful in the early detection of LGE positivity.

The usefulness of lactate/albumin ratio, C-reactive protein/albumin ratio, procalcitonin/albumin ratio, SOFA, and qSOFA in predicting the prognosis of patients with sepsis who presented to EDs

PurposeEarly identification of sepsis with a poor prognosis in the emergency department (ED) is crucial for prompt management and improved outcomes. This study aimed to examine the predictive value of sequential organ failure assessment (SOFA), quick SOFA (qSOFA), lactate to albumin ratio (LAR), C-reactive protein to albumin ratio (CAR), and procalcitonin to albumin ratio (PAR), obtained in the ED, as predictors for 28-day mortality in patients with sepsis and septic shock. Materials and methodsWe included 3499 patients (aged ≥19 years) from multicenter registry of the Korean Shock Society between October 2015 and December 2019. The SOFA score, qSOFA score, and lactate level at the time of registry enrollment were used. Albumin, C-reactive protein, and procalcitonin levels were obtained from the initial laboratory results measured upon ED arrival. We evaluated the predictive accuracy for 28-day mortality using the area under the receiver operating characteristic (AUROC) curve. A multivariable logistic regression analysis of the independent predictors of 28-day mortality was performed. The SOFA score, LAR, CAR, and PAR were converted to categorical variables using Youden's index and analyzed. Adjusting for confounding factors such as age, sex, comorbidities, and infection focus, adjusted odds ratios (aOR) were calculated. ResultsOf the 3499 patients, 2707 (77.4%) were survivors, whereas 792 (22.6%) were non-survivors. The median age of the patients was 70 (25th–75th percentiles, 61–78), and 2042 (58.4%) were male. LAR for predicting 28-day mortality had the highest AUROC, followed by the SOFA score (0.715; 95% confidence interval (CI): 0.69–0.74 and 0.669; 95% CI: 0.65–0.69, respectively). The multivariable logistic regression analysis revealed that the aOR of LAR >1.52 was 3.75 (95% CI: 3.16–4.45), and the aOR, of SOFA score at enrollment >7.5 was 2.67 (95% CI: 2.25–3.17). ConclusionThe results of this study showed that LAR is a relatively strong predictor of sepsis prognosis in the ED setting, indicating its potential as a straightforward and practical prognostic factor. This finding may assist healthcare providers in the ED by providing them with tools to risk-stratify patients and predict their mortality.