Initial Vital Signs Research Articles

Naloxone use by Aotearoa New Zealand emergency medical services, 2017-2021.

Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017-2021) and Wellington Free Ambulance (2018-2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population-years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care.

Spontaneous Iliac Artery Dissection in a 66-Year Old Male Complicated By Hemorrhage, GI Bleeding, and Bilateral DVT/PE

Spontaneous iliac artery dissection (IAD) is a rare medical condition with only a few cases being reported in the medical literature. Dissections typically involve the aorta and are not localized to the iliac arteries. Patients with spontaneous IAD typically present with symptoms that resemble peripheral artery disease, and cases are typically associated with connective tissue diseases such as Marfan syndrome and Ehlers-Danlos syndrome or high-risk states such as pregnancy and extreme athletics. There are some case reports that showed an association with hyperlipidemia, hypertension, and tobacco use. The most frequent complication of spontaneous IAD is rupture, and cases are typically treated endovascularly but may be treated with classical surgery such as in the case of rupture. Some cases have reportedly been treated with conservative management alone. In this case, we discuss a 66-year-old male with a past medical history of hyperlipidemia, hypertension, and tobacco use with no known diagnosis of connective tissue disease, and not in a high-risk state, who was found to have a spontaneous iliac artery dissection. He initially presented with sudden onset back pain that he described as a shooting pain that radiated into his head. He was also having right lower extremity discomfort. Initial vital signs were significant for tachycardia and hypertension, and physical exam was significant for tachycardia and diminished right posterior tibial and dorsalis pedis pulses. Laboratory workup was significant for a leukocytosis of 10.06 and creatinine of 1.52, consistent with acute kidney injury. Labs were otherwise unremarkable. Computed tomography angiogram (CTA) of the head and neck was negative for acute pathology, but CTA chest/abdomen/pelvis demonstrated arterial dissection that began at the origin of the right common iliac artery extending down to the right common femoral artery and also demonstrated a left renal infarct. A bare metal stent was placed by Interventional Radiology and the patient was started on dual antiplatelet therapy (DAPT) with a heparin drip and clopidogrel. Connective tissue disease workup was later performed including antinuclear antibody, rheumatoid factor, cyclic citrullinated peptide, and extractable nuclear antigen antibodies panel, which were all negative. Hospital stay was complicated by development of subarachnoid hemorrhage, intraventricular hemorrhage, subdural hematoma, and intradural hematoma that required laminoplasty and evacuation by Neurosurgery. DAPT was discontinued and the patient was later restarted on aspirin only. The patient then developed a cecal bleed that required clipping by Gastroenterology. Aspirin was discontinued and he then developed bilateral lower extremity deep venous thromboses and pulmonary emboli. He was started on enoxaparin with the assistance of Hematology and was later transitioned to apixaban with no complications. This case supports comorbidities as risk factors for spontaneous IAD and raises the need for formal screening and surveillance guidelines for these patients, as there are currently no guidelines in place. This case also demonstrates the complications that can occur with DAPT and anticoagulants and provides a manner in which to cautiously initiate anticoagulation in patients with high risk of bleeding while also preventing the development of further thrombi.

A study on the characteristics of patients visiting the pediatric emergency department with post-tonsillectomy hemorrhage

Purpose: This study was performed to identify risk factors associated with post-tonsillectomy hemorrhage (PTH)-related hospitalization in pediatric patients visiting an emergency department (ED).Methods: We retrospectively reviewed the medical records of patients who underwent tonsillectomy at a single children’s hospital ED from January 2009 through December 2020. Data were collected on patient demographics, chief complaints, surgical methods, postoperative days, initial vital signs, and laboratory findings. The study population was divided into hospitalized and discharged groups.Results: Among a total of 2,716 patients reviewed, 67 met the inclusion criteria. The hospitalized group showed a lower median systolic blood pressure (108.0 [interquartile range, 82.0-134.0] vs. 118.5 [89.8-147.2] mmHg; P = 0.021) and a faster median respiratory rate (23.0 [18.0-28.0] vs. 20.0 [17.0-23.0] breaths/minute; P = 0.019), compared with the discharged group. Multivariable logistic regression identified systolic blood pressure under 100 mmHg (odds ratio, 5.21; 95% confidence interval, 1.17-37.60) and respiratory rate over 24 breaths/minute (7.31; 1.07-145.79) as the factors associated with PTH-related hospitalization.Conclusion: When pediatric patients visit EDs for PTH, close monitoring or hospitalization may be needed in those with low systolic blood pressure or rapid respiratory rate.

Initial Vital Signs in Traumatized Children Determine the Length of Stay in Intensive Care Unit

Initial Vital Signs in Traumatized Children Determine the Length of Stay in Intensive Care Unit

Abstract 13611: Right Ventricular Perforation and Subsequent Tamponade Due to Fractured Inferior Vena Cava Filter Strut

Description of Case: A 39-year-old woman with a remote history of unprovoked pulmonary embolism (PE) treated with a retrievable inferior vena cava (IVC) filter presented with chest pain and syncope. Initial vital signs and examination were unremarkable. ECG showed diffuse ST elevations with PR depression consistent with acute pericarditis (Figure 1A). Given her history, CT angiogram (CTA) was performed and revealed complex pericardial effusion without PE. Echocardiogram confirmed large pericardial effusion with evidence of right ventricular diastolic collapse, raising concern for impending cardiac tamponade (Figure 1B). Urgent pericardiocentesis yielded 500 mL of sanguineous fluid, with resolution of effusion. A pericardial drain was left in place. Overnight she became hypotensive, tachycardic, diaphoretic, with muffled heart sounds on exam. Rapid re-accumulation of blood was noted from the drain, confirmed by repeat echo showing enlargement of the pericardial effusion. She was diagnosed with recurrent hemorrhagic pericardial effusion (HPE) of unclear etiology and was emergently taken for mediastinal exploration, where a metal shard measuring 2.2 cm was seen protruding though the RV (Figure 1C), confirmed on intraoperative TEE (Figure 1D). It was determined that a fractured IVC filter strut had migrated into the RV causing perforation and recurrent HPE. The strut was removed and RV defect patched. The patient did well post-operatively without effusion recurrence. Follow up CTA confirmed fractured IVC filter strut, with another filter strut also seen extending through the IVC wall (Figure E). Discussion: Rapid reaccumulation of a hemorrhagic, hemodynamically significant pericardial effusion without clear etiology, as in this case, should prompt consideration of surgical exploration to assess for bleeding source. As strut fractures are a known complication of retrievable IVC filters, these filters should be removed when no longer indicated.

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data?

Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. Prognostic and Epidemiological; Level III.

Prognostic value of hemoglobin-to-red cell distribution width ratio in patients with cardiopulmonary resuscitation after out-of-hospital cardiac arrest

To investigate the prognostic value of hemoglobin-to-red cell distribution width ratio (HRR) in patients with cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA). A retrospective study was conducted. Patients aged ≥ 18 years with OHCA who were transferred to intensive care unit (ICU) after successful CPR from the emergency room of the First Affiliated Hospital of Zhengzhou University from August 2016 to February 2022 were enrolled. General clinical data, initial vital signs, acute physiology and chronic health evaluation II (APACHE II), Glasgow coma scale (GCS), first laboratory indicators after admission to ICU [including white blood cell count (WBC), red blood cell count (RBC), hemoglobin (Hb), pH value, lactic acid (Lac), 6-hour lactic acid clearance (LCR), red cell distribution width (RDW), HRR], length of ICU stay were collected. According to whether the patients died in hospital, the patients were divided into survival group and death group. Binary Logistic regression was used to analyze the independent factors influencing the prognosis of patients after CPR. Receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of independent influencing factors for the prognosis of patients after CPR. A total of 122 patients were enrolled after OHCA CPR, of which 88 died in hospital, the in-hospital mortality was 72.13%. There were no significant differences in age, past medical history, initial vital signs and WBC in ICU between the two groups. Compared with the death group, the survival group had higher GCS score, RBC, Hb, pH value, 6-hour LCR, HRR, lower APACHE II score, Lac, RDW level, and longer length of ICU stay. Multivariate Logistic regression analysis showed that APACHE II score, GCS score, 6-hour LCR, HRR, length of ICU stay were independent factors influencing the prognosis of patients after CPR [APACHE II score: odds ratio (OR) = 0.784, 95% confidence interval (95%CI) was 0.683-0.901, P = 0.001; GCS score: OR = 1.390, 95%CI was 1.059-1.823, P = 0.018; 6-hour LCR: OR = 1.039, 95%CI was 1.015-1.064, P = 0.001; HRR: OR = 2.047, 95%CI was 1.383-3.029, P < 0.001; length of ICU stay: OR = 1.128, 95%CI was 1.046-1.216, P = 0.002]. ROC curve analysis showed that HRR, 6-hour LCR and APACHE II score could predict the prognosis of patients after CPR. The sensitivity was 85.3% and the specificity was 54.5% when the area under the ROC curve (AUC) of HRR was 0.731, and the cut-off value was 8.555. The sensitivity was 88.2% and the specificity was 46.6%, when the AUC of 6-hour LCR was 0.701, and the cut-off value was 28.947%. The sensitivity was 73.9% and the specificity was 79.4% when the AUC of APACHE II score was 0.848, the cut-off value was 22.000. The predictive value of the combination of HRR and 6-hour LCR was higher than that of a single index. The sensitivity was 79.3% and the specificity was 76.1%, when the AUC was 0.796, the cut-off value was 0.296. HRR, 6-hour LCR and APACHE II score have high prognostic value in patients with OHCA after CPR. HRR < 8.555, 6-hour LCR < 28.947% and APACHE II score > 22.000 indicated poor prognosis.

The reverse shock index multiplied by the Glasgow Coma Scale score can predict the need for initial resuscitation in patients suspected of sepsis.

For patients suspected of sepsis, early recognition of the need for initial resuscitation is key in management. This study evaluated the ability of a modified shock index - the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) - to predict the need for initial resuscitation in patients with sepsis. This retrospective study involved adults with infection who were admitted to a Japanese tertiary care hospital from an emergency department between January and November 2020. The rSIG, modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), and original shock index (SI) values were recorded using initial vital signs. The primary outcome was the area under the receiver-operating characteristic curve (AUROC) for the composite outcome consisting of vasopressor use, mechanical ventilation, and 72-h mortality. Secondary outcomes were the AUROCs for each component of the primary outcome and 28-day mortality. As a result, the primary outcome was met by 67 of the 724 patients (9%). The AUROC was significantly higher for the rSIG than for the other tools (rSIG 0.84 [0.78 - 0.88]; MEWS 0.78 [0.71 - 0.84]; qSOFA 0.72 [0.65 - 0.79]; SI 0.80 [0.74 - 0.85]). Compared with MEWS and qSOFA, the rSIG also had a higher AUROC for vasopressor use and mechanical ventilation, but not for 72-h mortality or in-hospital mortality. The rSIG could be a simple and reliable predictor of the need for initial resuscitation in patients suspected of sepsis.

Performance Assessment of Out-of-Hospital Use of Pelvic Circumferential Compression Devices for Severely Injured Patients in Switzerland: A Nationwide Retrospective Cross-Sectional Study.

Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital setting on a nationwide scale (Switzerland) and determine the sensitivity, specificity and rates of over- and under-triage of the current application practices. The secondary objective was to identify pre-hospital factors associated with unstable pelvic fractures. Retrospective cross-sectional study using anonymized patient data (1 January 2015-31 December 2020) from the Swiss Trauma Registry (STR). Based on AIS scores, patients were assigned a unique principal diagnosis among three categories (unstable pelvic fracture-stable pelvic fracture-other) and assessed for use or not of PCCD. Secondarily, patient characteristics, initial pre-hospital vital signs, means of pre-hospital transport and trauma mechanism were also extracted from the database. 2790 patients were included for analysis. A PCCD was used in 387 (13.9%) patients. In the PCCD group, 176 (45.5%) had an unstable pelvic fracture, 52 (13.4%) a stable pelvic fracture and 159 (41.1%) an injury unrelated to the pelvic region. In the group who did not receive a PCCD, 214 (8.9%) had an unstable pelvic fracture, 182 (7.6%) a stable pelvic fracture and 2007 (83.5%) an injury unrelated to the pelvic region. The nationwide sensitivity of PCCD application was 45.1% (95% CI 40.1-50.2), the specificity 91.2% (95% CI 90-92.3), with both over- and under-triage rates of 55%. The prevalence of unstable fractures in our population was 14% (390/2790). We identified female sex, younger age, lower systolic blood pressure, higher shock index, pedestrian hit and fall ≥3 m as possible risk factors for an unstable pelvic fracture. Our results demonstrate a nationwide both over- and under-triage rate of 55% for out-of-hospital PCCD application. Female gender, younger age, lower blood pressure, higher shock index, pedestrian hit and fall >3 m are possible risk factors for unstable pelvic fracture, but it remains unclear if those parameters are relevant clinically to perform pre-hospital triage.

Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?

The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries. All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed. Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific). Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations. Diagnostic Test/Criteria; Level III.

Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey.

Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Of 435million adult ED visits during 2016-2019, there were ≈5.3million related to asthma (1.3million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.

Symptoms: Abdominal Pain, Diaphoresis, Fever, Nausea, and Constipation

Symptoms: Abdominal Pain, Diaphoresis, Fever, Nausea, and Constipation

Effect of Antithrombin III Administration on the Prognosis of Severe Trauma Patients with Disseminated Intravascular Coagulation.

We aimed to investigate the effects of antithrombin III administration on the prognosis of severe trauma patients with disseminated intravascular coagulation (DIC). Medical records of a total of 4023 patients who were admitted to the intensive care unit (ICU) at the single regional trauma center from January 2016 to December 2020 were retrospectively analyzed. After the exclusion of young patients (<15 years old), mild trauma (ISS < 16), non DIC, etc., a total of 140 patients were included in the study. These patients were classified into antithrombin III-administered and non-antithrombin III-administered groups. Clinical data, including laboratory findings, trauma- and ICU-related severity scores, prognosis (including length of hospital stay), and need for organ support, were retrospectively collected. We evaluated the characteristics of the two groups, and compared and analyzed the vital signs, laboratory findings, prognosis, and clinical outcomes of each group. With this, we analyzed the effect of antithrombin III administration in severe trauma patients with DIC. Of the 140 patients, 61 were treated with antithrombin III. No significant difference was observed in the baseline characteristics between the two groups for initial laboratory results, initial vital signs, or trauma-related severity scores. The improvement of the sequential organ failure assessment (SOFA) score, a prognostic marker, was significantly greater in the administered group (p = 0.009). Additionally, the antithrombin-administered group showed a larger improvement in the SOFA score than the non-administered group (p = 0.002). However, there was no statistical difference between the two groups for the frequency or duration of organ support treatments (renal replacement therapy, mechanical ventilation), mortality, or length of hospital stay. Antithrombin III administration in severe trauma patients with DIC improved SOFA scores and aided in multi-organ dysfunction recovery. Appropriate indications should be studied to maximize the drug's improvement effect in patients with severe trauma in the future.

DEVELOPMENT OF A MACHINE-LEARNING ALGORITHM FOR PREDICTING THE ARRIVAL TIME AND ASSESSING FACTORS INFLUENCING PATIENT ARRIVAL AT HOSPITAL EMERGENCY DEPARTMENT – PRELIMINARY STUDY

Abstract: Healthcare is one of the most important topics affecting society. Emergency Departments (ED) play an important role in the patient treatment cycle, providing immediate and primary health care as well as access to services offered by hospitals. From a hospital's perspective, it is crucial that emergency departments are well organized in each hospital sector. One of the most important yet overlooked problems in the medical industry is emergency department congestion. An attempt was made to estimate and predict, using predictive models and machine learning algorithm techniques, the impact of factors on the arrival time of patients at hospital emergency department and to verify the effectiveness of teaching the models, along with a comparison which one is the best in predicting the phenomena. Research materials were source data from the 2018 National Hospital Ambulatory Medical Care Survey (NHAMCS) – Emergency Department. In this paper, a study was conducted to search for factors that could affect the frequent arrival of patients at emergency departments. A tool for predicting the expected arrival time, taking into account the current arduous conditions/factors in the ED, has the potential to improve situational awareness and contribute to mitigating problems related to congestion. It appears that the model can be used to enhance decision support systems by determining patient arrival times. The results obtained in the random forest regression algorithm are estimated at R2 of 86% and RMSE of 5.45. For research purposes, when attempting to analyze on a sample and reliable hospital department database, the random forest regressor method identified the most relevant factors such as initial vital signs. The results obtained allow for a broader view in the context of assessing the prevailing situation in the emergency department. In this case – examining the most relevant factors influencing patient arrival times. With the results of high effectiveness, an algorithm can be designed to assist emergency departments in proper monitoring of existing problems.

The Case Files

The Case Files

Abstract #1377584: Brain on Fire: A Case of Hashimoto's Encephalitis in a 29-Year-Old Female

A 29-year-old female presents to the hospital for insomnia, hallucination, and bizarre behavior. The patient had been feeling well until approximately three days early when she became psychotic after fasting from food for three days. She began having auditory and visual hallucinations and then started having seizures. Initially, the patient was admitted to a hospital in another city where she was diagnosed with Autoimmune Encephalitis for which she received IVIg. Brain MRI showed questionable T2 changes around the fourth ventricle on the left during hospital admission. The patient was discharged home after her symptoms improved. However, she was brought to our hospital for psychiatric consultation as her condition deteriorated. Upon arrival at Larkin Community Hospital, the patient was hemodynamically stable, breathing room air, and continued to complain of having delusions and hallucinations. Initial Vital Signs: BP: 122/74 mmHg, HR: 70 bpm, RR: 18, T: 98°F. weight 56.2 kg, BMI 24.21. She was in nonacute distress, although anxious with pressured speech. She was cooperative and able to follow commands and track the examiner. Her NIH Stroke Scale/Score (NIHSS) was 0 and Glasgow Coma Scale (GCS) was 15. She denied using illicit drugs, smoking, and alcohol. Neurology decided to repeat LP CSF r/o NMDA Antibody encephalitis and started empirically a 5-day course of azithromycin to cover for streptococcal infections while awaiting further results. Thyroglobulin antibodies were ordered to rule out Steroids Responsive Encephalopathy and it came back elevated (91.2). She was started on Solu-Medrol 500mg IV daily for 3 days which was increased to 1000mg IV daily to complete 5 days. Even though, she developed tachycardia in the 120s; she started feeling much better as well as improved her symptoms. “Steroid-responsive encephalopathy associated with autoimmune thyroiditis” (SREAT) is an uncommon condition that is associated with Hashimoto thyroiditis. It is also called Hashimoto encephalopathy (HE). This condition was originally described in 1966 by Brain et al1. HE is a rare disorder with an approximate prevalence of 2/100,0002. It affects women more often than men. This diagnosis is typically made when a patient has encephalopathy associated with antithyroid (anti-thyroid peroxidase [TPO]) and/or anti-thyroglobulin (TG) antibodies, when other causes have been excluded. The symptoms typically seen include subacute onset of confusion with altered level of consciousness, seizures, and myoclonus. Based on the literature review of 251 cases of SREAT by Laurent et al3, SREAT has various presentations including coma to isolated psychiatric disorder. This disorder is thought to be immune mediated as opposed to being the result of an altered thyroid state on the nervous system. In most of the reported cases of SREAT, the patients are euthyroid during the presentation of symptoms. However, the exact mechanism of SREAT is still unknown. The diagnosis is made after excluding other toxic, infectious, and metabolic causes of encephalopathy with examination of cerebrospinal fluid and neuroimaging.

Predictive indicators for determining red blood cell transfusion strategies in the emergency department.

Appropriate decision-making is critical for transfusions to prevent unnecessary adverse outcomes; however, transfusion in the emergency department (ED) can only be decided based on sparse evidence in a limited time window. This study aimed to identify factors associated with appropriate red blood cell (RBC) transfusion in the ED by analyzing retrospective data of patients who received transfusions at a single center. This study analyzed associations between transfusion appropriateness and sex, age, initial vital signs, an ED triage score [the Korean Triage and Acuity Scale (KTAS)], the length of stay, and the hemoglobin (Hb) concentration. Of 10 490 transfusions, 10 109 were deemed appropriate, and 381 were considered inappropriate. A younger age ( P < 0.001) and a KTAS level of 3-5 ( P = 0.028) were associated with inappropriate transfusions, after adjusting for O 2 saturation and the Hb level. In this single-center retrospective study, younger age and higher ED triage scores were associated with the appropriateness of RBC transfusions.

Effusive-constrictive pericarditis as first manifestation of late-onset systemic lupus erythematosus: an atypical case with grave prognosis

BackgroundSystemic lupus erythematosus (SLE) is a multisystem autoimmune disease that has a great diversity of clinical presentations and occurs mostly in young women. However, late-onset SLE does exist and seldom presents with an atypical case, including pericardial effusion (PE).Case presentationA 64 years old Asian woman presented with weakness all over the body and slight breathlessness for the past 2 days before the hospital admission. Her initial vital signs are 80/50 mmHg for blood pressure and a respiration rate of 24 breaths/min. Rhonchi were heard on the left lung and pitting edema on both legs. No evidence of any skin rash. Laboratory examination displayed anemia, hematocrit decrement, and azotemia. A 12-lead ECG demonstrated left-axis deviation with low voltage (Fig. 1). Chest X-ray showed left massive pleural effusion (Fig. 2). Transthoracic echocardiography revealed biatrial enlargement, normal EF 60%, diastolic dysfunction grade II, and thickening of the pericardium with mild circumferential PE corresponding with effusive-constrictive pericarditis (Fig. 3). The patient also brought CT angiography and cardiac MRI result, which confirmed pericarditis with PE. Treatment was initiated in ICU with fluid resuscitation of normal saline. The patient’s routine oral treatments, including furosemide, ramipril, colchicine, and bisoprolol, were carried on. An autoimmune workup was performed by a cardiologist and demonstrated an elevation in antinuclear antibody/ANA (IF) of 1:100, which finally unveiled a diagnosis of SLE. Pericardial effusion is one critical condition to consider, despite it being an uncommon presentation in late-onset SLE. Mild pericarditis in an SLE case can be treated with corticosteroid administration. Colchicine also has been found to reduce the risk of pericarditis recurrence. However, an atypical presentation from this case led to a slightly delayed treatment that escalated the morbidity and mortality risk. The patient had a sudden cardiac arrest and passed away 3 days after being treated.Fig. 1Initial electrocardiogram demonstrated left-axis deviation, low voltage QRS complex and T-wave inversion on lead V1–V3Fig. 2Chest radiograph showed left massive pleural effusionFig. 3Transthoracic echocardiogram displayed increased left ventricular filling pressure with diastolic dysfunction grade III, mild circumferential pericardial effusion with adjacent pleural effusionConclusionsAtypical presentation during late-onset SLE, mainly in the form of pericardial effusion even constrictive pericarditis, should be taken into a consideration since they are a scarce feature in SLE patients. Swift recognition and prompt treatment are important for the optimal outcome.

Toxic Epidermal Necrolysis as a Result of Hair Dye Allergy

More cases of hair dye allergy and poisoning are being presented to the Emergency Department (ED). There were rare TEN cases due to the hair dye in the literature. An 18-year-old female presented to our ED with the complaint of a common rash in her whole body, edema on her face that closed her eyes, and blisters on her face and neck. Her relatives reported that she dyed her hair 4 days ago 5 times in 24 hours. her initial vital signs were as follows: Blood pressure: 90/55 mmHg, Heart Rate:128 beats /min, Respiratory Rate: 18 beats/min, Oxygen saturation:100%, Body Temparature:40.3 2C. According to her history and physical examination, she was diagnosed with toxic epidermal necrolysis. According to starting the appropriate treatment modalities immediately in ED, she was discharged with full recovery in spite of her high predicted mortality. Although emergency medicine physicians encounter TEN patients infrequently, they must be aware of and initiate the appropriate treatment modalities immediately.