Initial Respiratory Rate Research Articles

Regression and Neural Network Analysis of the System of Cardiorespiratory Synchronism Parameters to Predict the Minimum Limit of the Synchronization Range

In order to improve the existing step-by-step principle of determining the limits of the range of cardiorespiratory synchronization (CRS) and the regulatory and adaptive capabilities of the human body, a regression analysis of measurements of the CRS parameters system was carried out. Statistical prediction of the minimum limit of the synchronization range in the CRS method was performed using linear, nonlinear multiple regression models, as well as neural network regression. The following parameters were used as the basis for predicting the minimum limit of the synchronization range: initial heart rate, initial respiratory rate, age and gender. The variable initial heart rate contributed the most to all regression models. A comparative analysis of the quality indicators of all models showed that the prediction of the minimum limit of the synchronization range can be carried out both by linear multiple regression and using neural network regression implemented by means of a 3-4-1 multilayer perceptrons. However, having already had a NN-regression forecast of maximum limit of the synchronization range, as well as a NN-classification of the level of regulatory-adaptive status, the use of NN-regression will be proposed as the main forecasting method for its implementation in the software of the CRS measurement system.

Crystalloid Fluid Management of Non-Traumatic Hypotension by New South Wales Ambulance

Introduction Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids’ impact on blood pressure changes. Methods This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. Results Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann’s solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500–600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. Conclusion This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.

Application of 24-h respiratory rate and oxygenation index variation to predict the outcome of high-flow nasal cannula therapy in patients with acute hypoxemic respiratory failure in arespiratory intensive care unit.

Background: An evaluation system is urgently needed to describe early predictors of the outcome of high-flow nasal cannula (HFNC) oxygen therapy in acute hypoxemic respiratory failure (AHRF) patients. Methods: All consecutive AHRF patients in aRespiratory Intensive Care Unit(RICU) receiving HFNC therapy between January 2019 and December 2021 were enrolled. Results: Of the 106 enrolled AHRF subjects, 57 (53.8%) succeeded in HFNC therapy and 49 (46.2%) failed. Being male (p = 0.006), initial respiratory rate oxygenation (ROX) index (p = 0.011), Acute Physiology and Chronic Health Evaluation II score (p = 0.007) and 24-h ROX index variation rate (p = 0.004) were independent factors of HFNC outcome; among these, 24-h ROX index variation rate (area under the curve =0.825) was the best evaluation indicator. Conclusion: 24-h ROX index variation rate, introduced by our study, has shown the best potential to predict HFNC outcome in AHRF patients.

Early prediction of delirium upon intensive care unit admission: Model development, validation, and deployment

Study objectiveTo develop, validate, and deploy models for predicting delirium in critically ill adult patients as early as upon intensive care unit (ICU) admission. DesignRetrospective cohort study. SettingSingle university teaching hospital in Taipei, Taiwan. Patients6238 critically ill patients from August 2020 to August 2021. MeasurementsData were extracted, pre-processed, and split into training and testing datasets based on the time period. Eligible variables included demographic characteristics, Glasgow Coma Scale, vital signs parameters, treatments, and laboratory data. The predicted outcome was delirium, defined as any positive result (a score ≥ 4) of the Intensive Care Delirium Screening Checklist that was assessed by primary care nurses in each 8-h shift within 48 h after ICU admission. We trained models to predict delirium upon ICU admission (ADM) and at 24 h (24H) after ICU admission by using logistic regression (LR), gradient boosted trees (GBT), and deep learning (DL) algorithms and compared the models' performance. Main resultsEight features were extracted from the eligible features to train the ADM models, including age, body mass index, medical history of dementia, postoperative intensive monitoring, elective surgery, pre-ICU hospital stays, and GCS score and initial respiratory rate upon ICU admission. In the ADM testing dataset, the incidence of ICU delirium occurred within 24 h and 48 h was 32.9% and 36.2%, respectively. The area under the receiver operating characteristic curve (AUROC) (0.858, 95% CI 0.835–0.879) and area under the precision-recall curve (AUPRC) (0.814, 95% CI 0.780–0.844) for the ADM GBT model were the highest. The Brier scores of the ADM LR, GBT, and DL models were 0.149, 0.140, and 0.145, respectively. The AUROC (0.931, 95% CI 0.911–0.949) was the highest for the 24H DL model and the AUPRC (0.842, 95% CI 0.792–0.886) was the highest for the 24H LR model. ConclusionOur early prediction models based on data obtained upon ICU admission could achieve good performance in predicting delirium occurred within 48 h after ICU admission. Our 24-h models can improve delirium prediction for patients discharged >1 day after ICU admission.

Empirically Derived Age-Based Vital Signs for Children in the Out-of-Hospital Setting.

To compare Pediatric Advanced Life Support (PALS) vital signs criteria to empirically derived vital signs cut-points for predicting out-of-hospital interventions in children. We performed a cross-sectional study of pediatric encounters (<18 years) using the 2019 to 2020 datasets of the National Emergency Medical Services Information System, which we randomly divided into equal size derivation and validation samples. We developed age-based centile curves for initial heart rate, respiratory rate, and systolic blood pressure using generalized additive models for location, scale, and shape, which we evaluated in the validation sample. In addition, we compared the proportion of encounters with at least 1 abnormal vital sign when using empirically derived and PALS criteria and calculated their associations with the delivery of out-of-hospital medical interventions (eg, vascular access, medication delivery, or airway maneuvers). We included 3,704,398 encounters. Among encounters with all 3 vital signs recorded (n=2,595,217), 45.9% had at least 1 abnormal vital sign using empirically derived criteria and 75.6% with PALS derived criteria. A higher proportion of encounters with a heart rate, respiratory rate, or systolic blood pressure less than 10th or more than 90th age-based empirically derived percentile had medical interventions than those with abnormal vital signs using PALS criteria. PALS criteria classified a high proportion of children as having abnormal vital signs. Empirically derived vital signs developed from out-of-hospital encounters more accurately predict the delivery of the out-of-hospital medical interventions. If externally validated and correlated to inhospital outcomes, these cut-points may provide a useful assessment tool for children in the out-of-hospital setting.

Prehospital characteristics of COVID-19 patients transported by emergency medical service and the predictors of a prehospital sudden deterioration in Addis Ababa, Ethiopia

BackgroundSeverally ill COVID-19 patients may require urgent transport to a specialized facility for advanced care. Prehospital transport is inherently risky; the patient’s health may deteriorate, and potentially fatal situations may arise. Hence, early detection of clinically worsening patients in a prehospital setting may enable selecting the best receiving facility, arranging for swift transportation, and providing the most accurate and timely therapies. The incidence and predictors of abrupt prehospital clinical deterioration among critically ill patients in Ethiopia are relatively limited.Study objectivesThis study was conducted to determine the incidence of sudden clinical deterioration during prehospital transportation and its predictors.MethodsA prospective cohort study of 591 COVID-19 patients transported by a public EMS in Addis Ababa. For data entry, Epi data V4.2 and SPSS V 25 were used for analysis. To control the effect of confounders, the candidate variables for multivariable analysis were chosen using a p 0.25 inclusion threshold from the bivariate analysis. A statistically significant association was declared at adjusted relative risk (ARR) ≠ 1 with a 95 % confidence interval (CI) and a p value < 0.05 after adjusting for potential confounders.ResultsThe incidence of prehospital sudden clinical deterioration in this study was 10.8%. The independent predictors of prehospital sudden clinical deterioration were total prehospital time [ARR 1.03 (95%; CI 1.00–1.06)], queuing delays [ARR 1.03 (95%; CI 1.00–1.06)], initial prehospital respiratory rate [ARR 1.07 (95% CI 1.01–1.13)], and diabetic mellitus [ARR 1.06 (95%; CI 1.01–1.11)].ConclusionIn the current study, one in every ten COVID-19 patients experienced a clinical deterioration while an EMS provider was present. The factors that determined rapid deterioration were total prehospital time, queueing delays, the initial respiratory rate, and diabetes mellitus. Queueing delays should be managed in order to find a way to decrease overall prehospital time. According to this finding, more research on prehospital intervention and indicators of prehospital clinical deterioration in Ethiopia is warranted.

Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India.

Noninvasive ventilation (NIV) is an established first-line treatment of acute respiratory failure both in emergency departments (ED) and intensive care unit (ICU) settings. It is however not always successful. Prospective, observational study was done among patients above 18 years presenting with acute respiratory failure initiated on NIV. Patients were placed in one of two groups covering successful NIV treatment and NIV failure. Two groups were compared on four variables: initial respiratory rate (RR), initial high-sensitivity C-reactive protein (hs-CRP), PaO2/FiO2 ratio (p/f ratio), and heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score at the end of 1 hour of initiation of NIV. A total of 104 patients fulfilling the inclusion criteria were included in the study, of which 55 (52.88%) were exclusively treated with NIV (NIV success group), and 49 (47.11%) required endotracheal intubation and mechanical ventilation (NIV failure group). Noninvasive ventilation failure group had a higher mean initial RR compared with NIV success group (40.65 ± 3.88 vs 31.98 ± 3.15, p <0.001). Mean initial PaO2/FiO2 ratio was also significantly lower in the NIV failure group (184.57 ± 50.33 vs 277.29 ± 34.70, p <0.001). Odds ratio for successful NIV treatment with a high initial RR was 0.503 (95% confidence interval (CI), 0.390-0.649) and with a higher initial PaO2/FiO2 ratio was 1.053 (95% CI: 1.032-1.071 and with a HACOR score of >5 at the end of 1 hour of initiation of NIV was highly associated with NIV failure (p <0.001). A high initial level of hs-CRP was 0.949 (95% CI: 0.927-0.970). Noninvasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented. Mathen PG, Kumar KPG, Mohan N, Sreekrishnan TP, Nair SB, Krishnan AK, et al. Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India. Indian J Crit Care Med 2022;26(10):1115-1119.

Association between prehospital shock index and mortality among patients with COVID-19 disease

BackgroundThere exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting. MethodsWe retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia. ResultsWe analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years].Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10−3).Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30.The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l−1.Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93–0.98;p = 10−3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02–1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03–1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87–0.98;p = 0.01 P < 10−3) and GCSi (aOR, 0.90; 95% CI: 0.82–0.99;p = 0.04).Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality. ConclusionNeither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.

Impact of timing of preoperative gabapentin administration on postoperative somnolence.

Enhanced Recovery After Surgery (ERAS) is a multimodal protocol aimed to improve quality of postoperative recovery, minimize complications, and optimize overall self-regulation. Preoperative gabapentin decreases postoperative pain but can be associated with prolonged postoperative somnolence and respiratory depression risk. Although it is known that gabapentin affects the postoperative course, it is unclear if the timing of preoperative administration affects this finding. This study aims to assess the optimal preoperative timing for gabapentin administration in patients undergoing gynecologic surgery to minimize postoperative somnolence risk. A retrospective cohort study evaluated patients who underwent major gynecologic surgery and received preoperative gabapentin. Patients were grouped based on timing from gabapentin administration to surgical incision (<4h group vs.≥4h group). Preoperative, intraoperative, and postoperative data were abstracted and compared. Univariate associations between the timing of gabapentin administration and the patient and surgical characteristics and outcomes were tested utilizing two-sample equal-variance t-tests, linear model ANOVA, or Fisher's exact tests. Associations between the timing of gabapentin administration and the time until the Richmond Agitation Sedation Scale (RASS) score of 0 were modeled utilizing linear regression, adjusted for age, initial postoperative anesthesia care unit (PACU), RASS score, and postoperative narcotics. Each group contained 127 patients. Demographics were similar except for age (<4h group mean=44.2 years;≥4h group mean=40.5 years; p=0.021), chronic pain (<4h group=17.6%;≥4h group=43.3%; p<0.001), and surgical indication (<4h group=pelvic pain [29.1%];≥4h group=pelvic pain [51.2%]; p=0.007). The <4h group had a similar postoperative narcotic administration (<4h group mean morphine milligram equivalents [MME]=3.667;≥4h group mean MME=4.833; p=0.185). The minutes from surgical closure until the patient received a RASS score of 0 and initial PACU pain score (Visual Analogue Scale [VAS]) were similar. The initial PACU oxygen administration volume, hours from surgical closure until the patient transitioned to room air, and initial PACU respiratory rate were similar. The PACU duration, admission secondary to somnolence, and initial PACU Glasgow Coma Scale (GCS) score showed no difference. Postoperative nausea/vomiting was decreased in the≥4h group (<4h group=24.4%;≥4h group=13.4%; p-value=0.036), and urinary retention (<4h group=14.2%;≥4h group=5.5%; p-value=0.033) was decreased in the≥4h group. The timing of gabapentin administration less than or more than 4h preoperatively in patients ≥18 years does not significantly affect postoperative somnolence or respiratory depression. Further, it does not have a significant effect on GCS scores or VAS scores.

Out-of-hospital, non-invasive, positive-pressure ventilation for acute dyspnea.

BackgroundEmergency medical services (EMS) patients with acute dyspnea require prompt treatment. Limited data describe out‐of‐hospital dyspnea treatment with non‐invasive, positive‐pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bi‐level positive air pressure (BPAP). We sought to determine the course and outcomes of out‐of‐hospital acute dyspnea patients treated with NIPPV.MethodsWe analyzed retrospective data on 1289 EMS agencies from the ESO Data Collaborative (ESO, Inc., Austin, TX) between January and December 2018. We defined acute dyspnea as adults with an initial respiratory rate ≥ 30 breaths/min (bpm), with a primary or secondary EMS subjective impression of a respiratory condition, who received oxygen and/or a respiratory medication and had 2 or more recordings of respiratory rate (RR). We excluded patients with trauma and those with altered mental status. We identified cases receiving care with and without NIPPV. The primary outcome was change in respiratory rate (RR), censored at 90 minutes of treatment. We compared baseline characteristics between NIPPV and non‐NIPPV patients. We compared RR changes between NIPPV and non‐NIPPV patients at 20 and 40 minutes of treatment. Using mixed linear, fractional polynomial, and multiple spline models, we examined the association of out‐of‐hospital NIPPV with overall change in RR. Secondary outcomes included whether the patient received advanced airway treatment (intubation, supraglottic airway device, and/or cricothyroidotomy).ResultsWe analyzed 33,585 EMS encounters for patients with acute dyspnea, including 8,750 (26.1%) NIPPV and 24,835 (73.9%) non‐NIPPV encounters. Median treatment duration was similar between NIPPV and non‐NIPPV (23.3 minutes vs 23.6 minutes, rank‐sum P = 0.266). Common concurrent treatments included albuterol (NIPPV, 48.8%; non‐NIPPV, 46.2%), ipratropium bromide (27.9%, 24.8%), and methylprednisolone (24.9%, 18.5%). At 20 minutes, mean RR change was slightly lower for the NIPPV group than non‐NIPPV; −6.0 versus −6.8 breaths/min. At 40 minutes, mean RR change was similar between NIPPV and non‐NIPPV groups; −7.7 versus −7.9 breaths/min. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, NIPPV was associated with a smaller RR decrease across time than NIPPV; [NIPPV × time] interaction P < 0.001. Out‐of‐hospital advanced airway placement (endotracheal intubation or supraglottic airway insertion) was higher for NIPPV than non‐NIPPV group (2.3% vs 1.3%, odds ratio = 2.23, 95% confidence interval = 2.01–2.47).ConclusionsNIPPV has been proven to be an effective treatment for out‐of‐hospital patients experiencing acute dyspnea through prior studies. Our findings provide detailed insight into characteristics and use of NIPPV and highlight the commonality of this treatment modality with use in over 1 in 4 patients in respiratory distress.

39 Impact of timing of preoperative gabapentin administration on postoperative somnolence

Preoperative gabapentin administration decreases postoperative pain, but is associated with increased risk of prolonged postoperative somnolence and respiratory depression. This study aims to assess the optimal preoperative timing for gabapentin administration in patients undergoing gynecologic surgery to minimize risk of prolonged postoperative somnolence. A retrospective cohort study evaluated patients who underwent gynecologic surgery and received preoperative gabapentin. Patients were grouped based on timing from gabapentin administration to surgical incision (less than 4 hours vs. greater than or equal to 4 hours). Preoperative, intraoperative, and postoperative data was abstracted and compared. A total of 225 patients were included. Gabapentin was administered less than 4 hours prior to skin incision for 127 patients (group 1) and greater than or equal to 4 hours in 98 patients (group 2). Demographics were similar between the groups with the exception of chronic pain (group 1 = 17.6%; group 2 = 34.7%; P value 0.005) and surgical indication (group 1 = pelvic pain (29.1%); group 2 = pelvic pain (55.1%); P value < 0.001). Surgical approach was minimally invasive in 95.3% of patients in group 1 and 91.8% of patients in group 2. Hysterectomy was the most frequent procedure(group 1 = 50.4%; group 2 = 54.1%), followed by excision of endometriosis (group 1 = 27.6%; group 2 = 43.9%).Narcotic administration preoperatively (P value 0.35) and intraoperatively (P value 0.50) were similar between the two groups, while group 1 had a lower postoperative narcotic administration (group 1 median morphine milligram equivalents (MME) = 0.019; group 2 median MME = 7.50; P value < 0.001).The minutes from surgical closure until time the patient received a Richmond Agitation Sedation Scale (RASS) score of 0 and initial Post-Anesthesia Care Unit (PACU) pain score (VAS) were similar for both groups (P value = 0.46 and P value = 0.40, respectively). Initial PACU oxygen administration volume (P value = 0.26), hours from surgical closure until patient transitioned to room air (P value = 0.82), and initial PACU respiratory rate (P value = 0.92) were similar between both groups. PACU stay duration (P value = 0.45), unplanned admission secondary to excessive somnolence (P value = 0.58), and the initial PACU Glasgow Coma Scale (GCS) score (P value = 0.85) showed no statistically significant difference. Administration of gabapentin less than or greater than 4 hours preoperatively does not significantly affect postoperative somnolence or respiratory depression. However, administration of gabapentin within 4 hours of first incision was associated with less postoperative narcotic administration, suggesting that the analgesic effects of gabapentin are more effective when given within 4 hours of surgery.

Factors associated to high-flow nasal cannula treatment failure in pediatric patients with respiratory failure in two pediatric intensive care units at high altitude

IntroductionAcute respiratory failure is the leading cause of hospitalization in pediatrics. High-flow nasal cannulas (HFNCs) offer a new alternative, but the evidence and indications are still debated. The performance of HFNCs at high altitude has not been described to date. ObjectiveTo describe the use of HFNCs in pediatric patients admitted with respiratory failure and explore the factors associated with treatment failure. MethodologyA prospective cohort study was carried out in patients between 1 month and 18 years of age managed with HFNCs. The demographic and treatment response data were recorded at baseline and after 1, 6 and 24h. The number of failures was determined, as well as the length of stay, complications and mortality. Patients with treatment failure were compared with the rest. ResultsA total of 539 patients were enrolled. Infants (70.9%) of male sex (58.4%) and airway diseases such as asthma and bronchiolitis (61.2%) were more frequent. There were 53 failures (9.8%), with 21 occurring in the first 24h. The median length of stay was 4 days (IQR 4); there were 5 deaths (0.9%) and 13 adverse events (epistaxis) (2.2%). Improvement was observed in vital signs and severity over time, with differences in the group that failed, but without interactions. The final logistic model established an independent relationship of failure between the hospital (OR 2.78, 95%CI 1.48–5.21) and the initial respiratory rate (OR 1.56, 95%CI 1.21–2.01). ConclusionsHFNCs afford good clinical response, with few complications and a low failure rate. The differences found between institutions suggest a subjective relationship in the decision of therapy failure.

Emergency Department Asthma "Spacing Trials": Institutional Variability and Time Cost.

Some admitting physicians request a medication-free interval ("spacing trial") in the emergency department (ED) to determine whether a patient with an acute exacerbation of asthma can be safely admitted to a hospital ward bed, where bronchodilators are only available every 4h. Our objectives were to estimate the frequency of ED spacing trials in different hospitals and their associated time cost. This multicenter retrospective cohort study examined patients admitted for asthma from 2015 to 2018. We included all university records and a random sample of records from two community hospitals in the same urban area. Two team members abstracted data from each record using recommended methods, with group consensus to resolve differences. Proportion confidence intervals were calculated using normal binomial approximation. We calculated mean differences in ED stay associated with spacing trials, using multivariable linear regression to adjust for age, hospital type, history of intubation, initial pulse, initial respiratory rate, initial signs of distress. We collected data from 274 patients in the university hospital, and 71 and 70 cases from the community hospitals. An explicit spacing trial was noted in 52 of 274 (19%) university hospital records vs. 3 of 141 (2%) community hospital records, with a difference of 17% (95% confidence interval [CI] 11-23%). Delayed patient decompensation occurred in 3%, with no difference between hospitals. Spacing trials were associated with an adjusted mean of 159min (95% CI 102-217min) increase in ED stay. The practice of spacing varies widely between hospitals and is associated with substantial delay without an apparent benefit.

298 Impact of Presenting Vital Signs on Outcomes of Patients Hospitalized with Coronavirus

Among patients admitted with coronavirus, vital signs recorded at initial emergency department (ED) presentation may inform outcomes. Our objective was to assess the impact of presenting vital signs on discharge after hospitalization, neurological sequelae, and hospital length of stay. We conducted a retrospective investigation at Elmhurst Hospital (Queens, New York) recognized as “the epicenter of the epicenter” of the 2020 coronavirus pandemic. Included were 2216 adult patients who tested positive for coronavirus. We studied vital signs recorded upon initial ED presentation including oxygen saturation, respiratory rate, temperature, heart rate, and blood pressure. We used multivariable logistic regression models to test for associations between presenting vital signs and discharge after hospitalization, neurological sequelae (cognitive/sensory/motor changes, new emotional instability, new onset seizures), and hospital length of stay. Upon abstract submission, data abstraction was still ongoing. Preliminary analysis suggested an association between higher initial oxygen saturation and increased odds of discharge after hospitalization (OR 1.108, 95% CI 1.004-1.223). It also suggested an association between higher initial respiratory rate and increased odds of neurological sequelae (OR 1.156, 95% CI 1.008-1.327). No association was observed between presenting temperature, heart rate, blood pressure, and outcomes. Among patients hospitalized with coronavirus, initial vital signs obtained at ED presentation provide useful prognostic information on short term outcomes.

Comparison of rates of opioid withdrawal symptoms and reversal of opioid toxicity in patients treated with two naloxone dosing regimens: a retrospective cohort study

Introduction When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated. Methods In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed a priori. Low dose naloxone (LDN; ≤0.15 mg) and high dose naloxone (HDN; >0.15 mg) patients were matched in a 1:4 ratio based upon initial respiratory rate (RR). The proportion of patients who developed OW and who met reversal criteria were compared between those treated initially with LDN or HDN. Odds ratios (OR) for OW and opioid reversal were obtained via logistic regression stratified by matched sets and adjusted for age, sex, pre-naloxone GCS, and presence of non-opioid drugs or alcohol. Results Eighty LDN patients were matched with 299 HDN patients. After adjustment, HDN patients were more likely than LDN patients to have OW after initial dose (OR = 8.43; 95%CI: 1.96, 36.3; p = 0.004) and after any dose (OR = 2.56; 95%CI: 1.17, 5.60; p = 0.019). HDN patients were more likely to meet reversal criteria after initial dose (OR = 2.73; 95%CI: 1.19, 6.26; p = 0.018) and after any dose (OR = 6.07; 95%CI: 1.81, 20.3; p = 0.003). Conclusions HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.

The Initial Factors with Strong Predictive Value in Relation to Six-Month Outcome among Patients Operated due to Extra-Axial Hematomas.

Introduction: Traumatic brain injuries (TBI) are a real social problem, with an upward trend worldwide. The most frequent consequence of a traumatic brain injury is extra-axial hemorrhage, i.e., an acute subdural (SDH) and epidural hematoma (EDH). Most of the factors affecting the prognosis have been analyzed on a wide group of traumatic brain injuries. Nonetheless, there are few studies analyzing factors influencing the prognosis regarding patients undergoing surgery due to acute subdural and epidural hematoma. The aim of this study was to identify the factors which have the strongest prognostic value in relation to the 6-month outcome of the patients undergoing surgery for SDH and EDH. Patients and methods: The study included a group of 128 patients with isolated craniocerebral injuries. Twenty eight patients were operated upon due to EDH, and a group of 100 patients were operated upon due to SDH. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, and time between the trauma and the surgery. All of these factors were correlated in a multivariate analysis with the six-month outcome in the Glasgow outcome scale. Results: The factors with the strongest prognostic value are GCS score, respiration rate, saturation, glycaemia and systolic blood pressure. Conclusion: Initial GCS score, respiratory rate, saturation, glycaemia and systolic blood pressure were the factors with the strongest prognostic value.

Establishing a Multicentre Trauma Registry in India: An Evaluation of Data Completeness.

The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02-2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries.

Neurogenic pulmonary edema following seizures: A retrospective computed tomography study

IntroductionData on the frequency and clinical relevance of neurogenic pulmonary edema (NPE) following epileptic seizures are limited. The aim of the present study was to analyze computed tomography (CT) examinations in patients with previous seizures. MethodIncidence of NPE and related clinical factors were retrospectively assessed in patients admitted because of epileptic seizures who underwent thoracic CT imaging as part of emergency diagnostics. ResultsBetween January 2010 and January 2016, we included all patients admitted with the International Classification of Diseases (ICD) diagnosis code of epileptic seizure or epilepsy and who underwent CT imaging, including visualization of the lungs, as part of emergency diagnostics.Of the 47 included patients, 26 patients had suffered from generalized convulsive seizures (GCS), 17 patients had focal seizures with impaired and 4 without impaired consciousness. Signs of NPE were present in 5 out of 47 patients; all 5 patients had GCS prior to thoracic CT scan (i.e., 19% of patients with GCS). In four out of five cases, a single seizure was described; in one case, the seizure was only partially witnessed, but the indirect clinical signs strongly suggested a GCS.Related factors such as the initial respiratory rate or the initial pCO2 value were not significantly different in patients with and without signs of NPE. ConclusionsThe highly selected and biased patient group warrants caution in the interpretation of the study results. Our data, however, confirm that signs of NPE appear to be rather frequent in patients with GCS. Its clinical significance as regards morbidity and sudden death in epilepsy is discussed.

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Background: Buprenorphine is a partial opioid agonist with a reported “ceiling effect” for respiratory depression. Despite implied safety, it has been associated with significant overdoses. Conflicting data exist regarding the response to naloxone. Research Question: How do the clinical characteristics and response to naloxone following buprenorphine overdose compare with those of heroin and methadone overdose? Methods: Consecutive patients admitted to two teaching hospitals with Glasgow Coma Score (GCS) <12 and at least two of the following three criteria were included in this 4year prospective. Observational Study: History suggestive of opioid overdose, pinpoint pupils, or initial respiratory rate <12/min. Demographics, intent, initial GCS, respiratory rate, oxygen saturation (SpO2), and vital signs were collected. Urine toxicological screening was performed and only overdoses involving the exclusive presence of 6-monoacetylmorphine, buprenorphine, or methadone were included. Cases involving multiple opioids were excluded, but cases with benzodiazepine coingestion were allowed. Patients were treated with naloxone and/or flumazenil. Antidote dose and order were at the discretion of the attending physician. Response to naloxone was considered “positive” if full awakening occurred or intubation avoided. Results: During the study, 160 patients were admitted for opioid overdose and 84 met inclusion criteria. These 84 were divided into three groups: heroin (n=26), buprenorphine (n=39), and methadone (n=19). Initial GCS, respiratory rate, SpO2, and blood gas analysis were similar between groups. Benzodiazepine coingestion was more common in the buprenorphine vs heroin group and suicide more common in the methadone vs buprenorphine group. Naloxone was administered in 65% of 84 patients. Buprenorphine-poisoned patients did not respond to 0.4– 0.8 mg intravenous naloxone (0/19). Conclusion: Buprenorphine overdose induced a typical opioid syndrome that was not reversed with naloxone. Critique: The strength of the study was a large number of patients and confirmation of toxins. Weaknesses include lack of data on pinpoint pupils (an inclusion criteria), subjective endpoints, preponderance of benzodiazepine co-ingestions, and lack of detailed naloxone dosing information. Implication for Toxicologists: This study gives further evidence that buprenorphine overdose produces a typical opioid toxidrome. If naloxone is used to treat suspected buprenorphine overdose, doses of 0.4 to 0.8 mg may be insufficient to reverse the clinical effects. Benzodiazepines are common coingestants.

P014: Comparison of prehospital administration of naloxone to patients with or without a history of an opioid overdose

Introduction: Introduction: Paramedics frequently make immediate life-altering decisions with minimal clinical information. This applies to their decision to treat an unconscious patient with naloxone when the history of an opioid overdose cannot be readily established. Among patients treated by paramedics with naloxone, our objective was to compare patient demographics, treatment interventions and clinical response between patients with and without a confirmed history of an opioid overdose. Methods: Methods: This was a retrospective cohort study design of consecutive patients treated with naloxone by paramedics between January 1, 2016, and June 30, 2017. Patients were classified based on whether paramedics did or did not document a history of an opioid overdose. Baseline characteristics, treatment interventions, and response to naloxone were compared between groups. Comparisons were done using a chi-squared or Fishers exact test. Results: Results: We identified 294 patients of whom 113 (38%) did not have a confirmed history of an opioid overdose. The groups were similar in gender, bystander CPR, and bystander administration of naloxone. There were no differences in the presence of pinpoint pupils, initial oxygen saturation, initial Glasgow Coma Score (GCS), respiratory rate, or time on scene. Both patient groups were managed similarly with respect to route of naloxone administration and the use of a bag valve mask. All patients who were intubated were in the no confirmed history group (n=5; p=.003). Post naloxone there were no differences in last recorded vital signs except the no confirmed history group was less likely to achieve a GCS 10 (57% versus 89%; p&lt;.001). The overall post-naloxone development of agitation (9%) was moderate while the need for physical/chemical restraint (2%) was low with no differences between groups. All patients were transported to the hospital. Conclusion: Conclusion: A substantial proportion of patients who received naloxone did not have a confirmed history of an opioid overdose. These patients closely resembled those with a confirmed history with respect to demographics and physical characteristics. The primary difference was a lower proportion of patients with no confirmed history who achieved a post naloxone GCS 10. Despite a moderate development of post naloxone agitation, paramedics were able to manage most of these patients without the use of physical/chemical restraints.