Emergency Department Injury Research Articles

Heart rate to identify non-febrile children with dehydration and acute kidney injury in emergency department: a prospective validation study

We previously developed and retrospectively validated the estimated percentage of heart rate variation (EHRV) as a predictor of the composite outcome of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile children. The current study aimed to prospectively validate EHRV as a predictor for dehydration or AKI in a different cohort of children attending the Pediatric Emergency Department. From July 2022 to August 2023, 256 pediatric patients aged 0–18 years attending the Pediatric Emergency Department were enrolled. EHRV was calculated as follows: [(HR at admission − 50th percentile of HR for age and sex)/HR at admission] × 100. Dehydration was categorized as < 5% or ≥ 5% fluid deficit. AKI was defined according to KDIGO creatinine criteria. Statistical analyses included receiver-operating characteristic (ROC) curves and logistic regression analysis. Among enrolled patients, 52 had ≥ 5% dehydration, 50 had AKI, and 16 had both conditions. EHRV demonstrated significant predictive ability for both ≥ 5% dehydration (AUROC = 0.71; 95% confidence interval (CI), 0.63–0.78; p < 0.001) and AKI (AUROC = 0.78; 95% CI, 0.71–0.84; p < 0.001). An EHRV > 24.5% was associated with an increased odds ratio (OR), adjusted for confounders, of ≥ 5% dehydration (OR = 3.5; 95% CI, 1.6–8.0; p = 0.003) and AKI (OR = 3.4; 95% CI, 1.6–7.3; p = 0.002). The sensitivity and specificity of this cut-off were 34% and 83% for ≥ 5% dehydration and 36% and 84% for AKI, respectively.Conclusions: This study prospectively validates the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. An EHRV > 24.5% could serve as a marker for suspecting dehydration or AKI. Further validation across diverse patient populations and settings is needed. What is Known:• An increased heart rate (HR) is a readily detectable sign of dehydration in children.• In a retrospective validation cohort, an estimated HR variation (EHRV) greater than 24.5% compared to the 50th percentile of HR was predictive of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile patients.What is New:• We prospectively validated the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting.• We confirmed that an EHRV greater than 24.5% is associated with increased odds of ≥ 5% dehydration and AKI.

Pediatric head injury guideline use in Sweden: a cross-sectional survey on determinants for successful implementation of a clinical practice guideline

BackgroundThe Scandinavian Neurotrauma Committee guideline (SNC-16) was developed and published in 2016, to aid clinicians in management of pediatric head injuries in Scandinavian emergency departments (ED). The objective of this study was to explore determinants for use of the SNC-16 guideline by Swedish ED physicians.MethodsThis is a nationwide, cross-sectional, web-based survey in Sweden. Using modified snowball sampling, physicians managing children in the ED were invited via e-mail to complete the validated Clinician Guideline Determinants Questionnaire between February and May, 2023. Baseline data, data on enablers and barriers for use of the SNC-16 guideline, and preferred routes for implementation and access of guidelines in general were collected and analyzed descriptively and exploratory with Chi-square and Fisher's tests.ResultsOf 595 invitations, 198 emergency physicians completed the survey (effective response rate 33.3%). There was a high reported use of the SNC-16 guideline (149/195; 76.4%) and a strong belief in its benefits for the patients (188/197; 95.4% agreement). Respondents generally agreed with the guideline's content (187/197; 94.9%) and found it easy to use and navigate (188/197; 95.4%). Some respondents (53/197; 26.9%) perceived a lack of organizational support needed to use the guideline. Implementation tools may be improved as only 58.9% (116/197) agreed that the guideline includes such. Only 37.6% (74/197) of the respondents agreed that the guideline clearly describes the underlying evidence supporting the recommendation. Most respondents prefer to consult colleagues (178/198; 89.9%) and guidelines (149/198; 75.3%) to gain knowledge to guide clinical decision making. Four types of enablers for guideline use emerged from free-text answers: ease of use and implementation, alignment with local guidelines and practice, advantages for stakeholders, and practicality and accessibility. Barriers for guideline use were manifested as: organizational challenges, medical concerns, and practical concerns.ConclusionsThe findings suggest high self-reported use of the SNC-16 guideline among Swedish ED physicians. In updated versions of the guideline, focus on improving implementation tools and descriptions of the underlying evidence may further facilitate adoption and adherence. Measures to improve organizational support for guideline use and involvement of patient representatives should also be considered.

The prevalence of incidental findings in computed tomography of the head in Pediatric Emergency Department

Introduction and aim. Computed tomography (CT) is the first imaging modality in the evaluation of children in case of patients with head injury in pediatric Emergency Departments (EDs). Radiological CT reports include not only lesions that are the main cause of the child’s complaints but also incidental findings. The objective of this study is to assess incidental findings observed in children who were admitted to the ED and had the head CT performed. Material and methods. This retrospective, cross-sectional study enrolled 644 children under the age of 18, from 1st January 2021 to 31st June 2021. Each child could have had one or more incidental findings in CT Results. Among all CT studies, incidental findings were found in 279 out of 644 (43.32%) cases, of which 73 (11.34%) had both lesions detected incidentally and related to the trauma. Conclusion. Head CT is an incredibly useful tool in the assessment of some head emergencies. However, evaluation of the prevalence of incidental findings is difficult. Most of them require no specific further investigation. Pediatricians, who order CTs in children, must be prepared to interpret and communicate findings to families and introduce treatment in necessary situations.

Pediatric skeletal injuries in emergency department; an alarm of child maltreatment in Egypt: A cross-sectional study

BackgroundChild physical abuse, a type of child maltreatment (CM), poses a significant global public health concern. Nonaccidental fractures and soft tissue injuries, which encompass any action that directly or indirectly harms a child, are the primary indicators of physical abuse in children. ObjectiveThis study aimed to investigate the prevalence, risk factors, and outcomes of accidental and nonaccidental skeletal fractures in a sample of Egyptian children. MethodsA cross-sectional analytical study was conducted between March 2022 and August 2022. A total of 156 children who presented with skeletal injuries and attended Mobarak Central Hospital were enrolled. Patients were subjected to full history taking, complete examination, and investigations. A structured questionnaire was administered to all the legal guardians. ResultsPhysical abuse was reported in 22.4 % of cases, while medical neglect was reported in 19.9 % of cases. The incidence of physical abuse was notably higher among children whose fathers were smokers and/or drug addicts (p ≤ 0.05). The most common form of physical abuse was hitting (94.3 %). Among skeletal injuries, fractures were predominant (94.3 %), primarily closed fractures associated with contusions. Fractures of the upper limb accounted for the highest incidence (94.3 %) of skeletal injuries, and 60 % of physically abused children experienced moderate-severity injuries. ConclusionThe most common fracture observed in abused children is the upper limb fracture, typically involving a single bone. Clinicians should be more vigilant in suspecting abuse, even in cases where there is an isolated fracture, and advocate for the development of parental training programs.

Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: a quality improvement project

IntroductionPain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many...

Management of acute Traumatic Brain Injury in emergency department: Systematic review

Management of acute Traumatic Brain Injury in emergency department: Systematic review

Seizure-Related Head Injuries: A Narrative Review.

Epilepsy is one of the most common neurological diseases. Epileptic seizures very often result in head injuries that may lead to many adverse consequences, both acute and chronic. They contribute to the need for hospitalization, modification of treatment, and a general decline in social productivity. The objective of our review is to characterize and assess management aspects of seizure-related head injuries (SRHIs) as an important and frequent clinical problem present in emergency department settings. PubMed and other relevant databases and websites were systematically searched for articles on traumatic brain injuries connected with the occurrence of seizures published from inception to 9 April 2024; then, we reviewed the available literature. Our review showed that SRHIs can lead to various acute complications, in some cases requiring hospitalization and neurosurgical intervention. Long-term complications and cognitive decline after injury might be present, eventually implying a negative impact on a patient's quality of life. Despite being frequent and clinically important, there are still no widely accepted, uniform recommendations for the management of patients with SRHIs. As such, a concise and standardized protocol for the management of seizure-related head injuries in emergency departments is worth consideration.

Suicide prevention-related Google searches and subsequent emergency department visits in California and Arizona, 2007–2015

IntroductionUnited States emergency departments (ED) visit rates for nonfatal self-harm increased by 42% from 2001 to 2016. Previous suicide mortality research has provided conflicting evidence on the use of suicide-related Internet searches as a surveillance tool for self-harm and suicidal ideation. However, few have used rigorous approaches to account for autocorrelation at the aggregate level, and none have focused on Internet searches related to suicide prevention. Methods and resultsOver a 9-year study period (2007–2015), suicidality-related search data were extracted using the Google Health Application Programming Interface (API) for Arizona and California – states, chosen for their differing age distributions and rigorous ED injury coding policies. We examined several combined suicide prevention-related search queries. Using autoregressive integration moving average (ARIMA) models and a Box-Jenkins approach, we assessed whether increased prevention-related Internet searches related to suicidality are predictive of lower subsequent ED visits related to suicidal ideation with or without self-harm injury. In both states, greater prevention-related queries were associated with lower ED visits approximately four to six weeks later. ConclusionsOur results indicate that Internet-based search volumes related to suicide prevention may have the potential to monitor suicidality and online suicide prevention resources offer meaningful opportunities for mental health support.

Role of point of care ultrasound and parathormone hormone in management of acute kidney injury in emergency department

ABSTRACT Background Role of point of care ultrasound in management of acute kidney injury (AKI) is still unclear. The discrimination between AKI and chronic kidney disease (CKD) in ED, especially in the absence of clear CKD history, represents a dilemma. Aim To test the accuracy of POCUS and intact parathormone hormone (iPTH) as differentiators between AKI and CKD, and to investigate the role of POCUS in management of AKI in the ED. Methods This prospective study involved 95 adult patients presented to ED of Alexandria Main University Hospital, with signs and/or symptoms suggesting renal impairment in the absence of prior renal functions tests from April 2022 to December 2022. POCUS was done and iPTH was measured for all enrolled patients. Validity of renal length and iPTH to discriminate AKI and CKD were tested. POCUS were used to identify different underlying causes of AKI. Results Renal length ≤ 9.62 cm could diagnose CKD (Area under curve-AUC 0.926) with 82.46% sensitivity, 92.11% specificity, 94.0% PPV and 77.8% NPV. Intact PTH level > 161 pg/ml could diagnose CKD (AUC 0.844) with 73.17% sensitivity, 92.11% specificity, 90.9% PPV and 76.1% NPV. Conclusion Both renal length and iPTH are accurate tests to differentiate AKI from CKD in ED. POCUS help identifying the different causes of AKI and reaching appropriate management decisions.

Incomplete Fractures of Distal Long Bones Among Children in Early Stages of Mobility: Few Concerns for Physical Child Abuse at a Single Pediatric Level I Trauma Center.

This study aimed to describe the characteristics, reported mechanism of injury, fracture morphology, and level of physical abuse concern among children in the early stages of mobility diagnosed with an incomplete distal extremity long bone fracture. A retrospective chart review was performed for all children aged 10 to 12 months with an incomplete fracture of a distal forearm or distal lower limb who were reportedly pulling up, cruising, or ambulating, and who were evaluated by the child abuse pediatrics team at a single pediatric level I trauma center. Of the 29 patients who met inclusion criteria, the child abuse pediatrics team had concerns about physical child abuse for 3 children. Not every case with an unknown or discrepant history of injury was deemed concerning for abuse, but all 3 for whom the team determined that concern was warranted had an unknown or discrepant history. All 3 of these children had distal forearm fractures; 1 child had multiple concomitant fractures (including a scapular fracture), and 2 had evidence of bone healing at initial presentation. Each of these observations raises concern for abusive injury based on current evidence. Both-bone buckle fractures of the radius/ulna and tibia/fibula were the most common type of incomplete distal fracture. This age group presents a unique challenge when designing evidence-based algorithms for the detection of occult injuries in emergency departments. Incomplete fractures of a distal limb are commonly related to a fall and may be considered "low specificity" for physical abuse. However, some publications conclude they should prompt universal physical abuse screening. Our small study indicated that the presence or absence of certain risk factors may provide additional information which could help guide the need for a more thorough evaluation for occult injury in early-mobile children with incomplete distal extremity long bone fractures. Ongoing research is warranted.

Burden and Severity of Injuries at the Emergency Department of a Tertiary Hospital in Botswana- Princess Marina Hospital

Purpose: Injuries constitute a leading and growing cause of emergency department (ED) visits in sub-Saharan Africa. Characteristics of ED injury patients have been well-described in many parts of the world; however, data remain scarce throughout Africa, Botswana included. We aimed to describe in detail injury-related ED visits at an urban public referral hospital in Botswana.&#x0D; Methodology: We conducted a retrospective chart review of all patients who presented to Princess Marina Hospital in Gaborone, Botswana, over a period of 4 randomly selected consecutive months. Demographic data, injury mechanism, type, severity and ED disposition were abstracted from the medical record into a Microsoft Access database designed for this study. Study variables were analyzed with summary statistics for frequencies, percentages, means, medians and relationships using SPSS. Injury severity was calculated for each patient using the modified Kampala Trauma Score.&#x0D; Results: 6715 ED visits occurred during the study period, and 1709 (25.5%) were injury related. Of these, 63.9% were male, 24.7% &lt;14 years old, 6.7% age 14-19, 49.1% 20-40, and 19.5% &gt;40. 35.9% were due to falls, 23.6% assault and 18.8% road traffic crashes. 40.5% isolated soft tissue injuries, 34.7% isolated extremity injuries, 9.4% multiple injuries and 5.3% head and neck injuries. Kampala Trauma Score II (KTS) was available for 76% of patients. 1.7% scored ≤6, 5.9% 7-8, and 92.4% 9-10. For patients with KTS ≤6, 18% died in the ED, 82% were admitted and 0% discharged home. For KTS 7-8, 0% died, 93.5% were admitted, 6.5% were discharged home. For KTS II 9-10, 0% died, 26% were admitted, 74% were discharged home.&#x0D; Unique Contribution to Theory, Practice and Policy: This study is among the first in Botswana to assess the burden of injuries using a validated injury severity scoring tool. Based on the study findings and applicability of the KTS II in our setting, we recommend that PMH ED incorporates and promotes a severity scoring system to help in planning and resource allocation. PMH ED receives many low acuity injuries therefore improving the availability of basic resources in local clinics may reduce overcrowding. Future studies should aim to involve multiple centers to get a true representation of injury burden in Botswana.

Defective Assistive Device Involvement in Older Adult Emergency Department Visits.

Many older adults adopt equipment to address physical limitations and reduce dependence on others to complete basic activities of daily living. Although a few prior studies have considered injuries associated with assistive devices for older adults, those studies focused on older adults' health and functional risks for injury. There is limited analysis of older adult injuries involving defective or malfunctioning assistive devices. Data from this study are from the National Electronic Surveillance System All Injury Program which collected data on consumer product-related injuries from a probability sample of 66 hospital Emergency Departments across the United States. Data from 30776 older adult Emergency Department (ED) injury narratives from 2016 to 2020 were coded according to the assistive device involved and whether malfunctioning led to the injury. The study team manually examined all narratives in which the assistive device was coded to have malfunctioned. A total of 10974 older adult ED cases were treated for 12488 injuries involving a defective device. Injuries included 4212 head and neck injuries (eg, concussion), 4317 trunk injuries (eg, hip fractures), and 3959 arm or leg injuries (eg, leg fracture). Of these patients, 4586 were admitted to a hospital ward for further evaluation and treatment. Seventy percent of these patients were injured while using a walker; in contrast, wheelchairs were implicated in only 4% of the above cases. Design flaws were identified in 8158 cases and part breakage/decoupling incidents in 2816 cases. Our findings provide evidence that assistive devices are actively involved in older adult injuries. Further research is needed to reduce injuries associated with assistive devices by educating patients and their careproviders about device use and assembly and developing effective methods for informing manufacturers about malfunctioning devices.

Association between normal saline infusion volume in the emergency department and acute kidney injury in heat stroke patients: a multicenter retrospective study

Background Previous studies have shown that intravenous normal saline (NS) may be associated with the incidence of acute kidney injury (AKI). This study aimed to evaluate the association between the volume of NS infusion and AKI in heat stroke (HS) patients. Methods This multicenter retrospective cohort study included 138 patients with HS. The primary outcome was the incidence of AKI. Secondary outcomes included the need for continuous renal replacement therapy (CRRT), admission to the intensive care unit (ICU), length of stay in the ICU and hospital, and in-hospital mortality. Multivariate regression models, random forest imputation, and genetic and propensity score matching were used to explore the relationship between NS infusion and outcomes. Results The mean volume of NS infusion in the emergency department (ED) was 3.02 ± 1.45 L. During hospitalization, 33 patients (23.91%) suffered from AKI. In the multivariate model, as a continuous variable (per 1 L), the volume of NS infusion was associated with the incidence of AKI (OR, 2.51; 95% CI, 1.43–4.40; p = .001), admission to the ICU (OR, 3.46; 95% CI 1.58–7.54; p = .002), and length of stay in the ICU (β, 1.00 days; 95% CI, 0.44–1.56; p < .001) and hospital (β, 1.41 days; 95% CI, 0.37–2.45; p = .008). These relationships also existed in the forest imputation cohort and matching cohort. There were no differences in the use of CRRT or in-hospital mortality. Conclusions The volume of NS infusion was associated with a significant increase in the incidence of AKI, admission to the ICU, and length of stay in the ICU and hospital among patients with HS.

Characteristics and outcomes of patients with symptomatic chronic myocardial injury in a Tanzanian emergency department: A prospective observational study.

Chronic myocardial injury is a condition defined by stably elevated cardiac biomarkers without acute myocardial ischemia. Although studies from high-income countries have reported that chronic myocardial injury predicts adverse prognosis, there are no published data about the condition in sub-Saharan Africa. Between November 2020 and January 2023, adult patients with chest pain or shortness of breath were recruited from an emergency department in Moshi, Tanzania. Medical history and point-of-care troponin T (cTnT) assays were obtained from participants; those whose initial and three-hour repeat cTnT values were abnormally elevated but within 11% of each other were defined as having chronic myocardial injury. Mortality was assessed thirty days following enrollment. Of 568 enrolled participants, 81 (14.3%) had chronic myocardial injury, 73 (12.9%) had acute myocardial injury, and 412 (72.5%) had undetectable cTnT values. Of participants with chronic myocardial injury, the mean (± sd) age was 61.5 (± 17.2) years, and the most common comorbidities were CKD (n = 65, 80%) and hypertension (n = 60, 74%). After adjusting for CKD, thirty-day mortality rates (38% vs. 36%, aOR 1.03, 95% CI: 0.52-2.03, p = 0.931) were similar between participants with chronic myocardial injury and those with acute myocardial injury, but significantly greater (38% vs. 13.6%, aOR 3.63, 95% CI: 1.98-6.65, p<0.001) among participants with chronic myocardial injury than those with undetectable cTnT values. In Tanzania, chronic myocardial injury is a poor prognostic indicator associated with high risk of short-term mortality. Clinicians practicing in this region should triage patients with stably elevated cTn levels in light of their increased risk.

Prevalence of Ankle Sprain in Recreational Football Players of Peshawar Sports Complex, Peshawar, Pakistan

Prevalence of Ankle Sprain in Recreational Football Players of Peshawar Sports Complex, Peshawar, Pakistan

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic

BackgroundInjuries, the leading cause of death in children 1–17 years old, are often preventable. Injury patterns are impacted by changes in the child’s environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic.MethodsThis multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00–T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020.ResultsThe study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (− 4.9%) and overexertion (− 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019.ConclusionsThe proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Emergency department evaluation of nurse triage questions about safe-at-home and abuse or neglect in traumatic ocular injuries

ObjectifEnviron 10 millions d'Américains subissent de la violence physique aux mains de leur partenaire intime (VC, pour violence conjugale). Les blessures oculaires examinées au service des urgences peuvent être un symptôme de VC; or, cette dernière est trop peu souvent déclarée dans la littérature médicale. Si l’équipe du service des urgences comprend l'incidence et les tendances en matière de blessures oculaires associées à la VC, elle sera mieux en mesure de déceler les patients à risque qui passeraient autrement inaperçus. NatureExamen rétrospectif de dossiers médicaux. ParticipantsPatients évalués au service des urgences en raison d'un traumatisme oculaire entre janvier 2018 et avril 2023 dans un important établissement de soins tertiaires. MéthodesLa population à l’étude a été identifiée d'après 3 éléments : le code du CIM-10, le sentiment de sécurité à la maison et l'impression du personnel infirmer en ce qui a trait au risque de sévices ou de négligence. Au cours du processus de triage, le personnel infirmier vérifiait d'abord si le patient se sentait en sécurité à son domicile (réponse « oui » ou « non ») pour ensuite signaler ses inquiétudes en matière de maltraitance (sévices, négligence, violence conjugale, agression sexuelle ou traite des personnes). RésultatsOn a recensé 2 653 993 visites au service des urgences et 16 737 traumatismes oculaires pendant la période à l’étude. De ce nombre, 1,1 % des patients (154 sur 14 457) ont répondu « Non » à la question « Vous sentez-vous en sécurité à la maison ? ». Le personnel infirmier a manifesté son inquiétude à l’égard de seulement 0,6 % des patients (82 sur 14 457). Les blessures oculaires des patients qui ont répondu « Non » à la question « Vous sentez-vous en sécurité à la maison ? » étaient plus graves et comprenaient notamment une fracture du maxillaire. Selon l'analyse de régression, les patients mariés, divorcés et veufs de même que les patients qui avaient une assurance privée étaient moins susceptibles de dire qu'ils ne se sentaient pas en sécurité à la maison que les patients célibataires inscrits au régime public d'assurance maladie (p < 0,05). ConclusionLes traumatismes oculaires des patients qui se présentent au service des urgences doivent attirer l'attention sur le risque de VC. Il est possible de mieux encadrer ces patients afin d'améliorer leur dépistage et leur prise en charge.

TiME OUT: Time-specific machine-learning evaluation to optimize ultramassive transfusion.

Ultramassive transfusion (UMT) is a resource-demanding intervention for trauma patients in hemorrhagic shock, and associated mortality rates remains high. Current research has been unable to identify a transfusion ceiling or point where UMT transitions from lifesaving to futility. Furthermore, little consideration has been given to how time-specific patient data points impact decisions with ongoing high-volume resuscitation. Therefore, this study sought to use time-specific machine learning modeling to predict mortality and identify parameters associated with survivability in trauma patients undergoing UMT. A retrospective review was conducted at a Level I trauma (2018-2021) and included trauma patients meeting criteria for UMT, defined as ≥20 red blood cell products within 24 hours of admission. Cross-sectional data were obtained from the blood bank and trauma registries, and time-specific data were obtained from the electronic medical record. Time-specific decision-tree models predicating mortality were generated and evaluated using area under the curve. In the 180 patients included, mortality rate was 40.5% at 48 hours and 52.2% overall. The deceased received significantly more blood products with a median of 71.5 total units compared with 55.5 in the survivors ( p < 0.001) and significantly greater rates of packed red blood cells and fresh frozen plasma at each time interval. Time-specific decision-tree models predicted mortality with an accuracy as high as 81%. In the early time intervals, hemodynamic stability, undergoing an emergency department thoracotomy, and injury severity were most predictive of survival, while, in the later intervals, markers of adequate resuscitation such as arterial pH and lactate level became more prominent. This study supports that the decision of "when to stop" in UMT resuscitation is not based exclusively on the number of units transfused but rather the complex integration of patient and time-specific data. Machine learning is an effective tool to investigate this concept, and further research is needed to refine and validate these time-specific decision-tree models. Prognostic and Epidemiological; Level IV.

183 A.P.B. DUMBLEDORE Study. Algorithm Pecarne to Bowl over raDiation and brush Up Management of Brain injury in wardLy Emergency Department: Outcomes and cRowding improved

183 A.P.B. DUMBLEDORE Study. Algorithm Pecarne to Bowl over raDiation and brush Up Management of Brain injury in wardLy Emergency Department: Outcomes and cRowding improved

PROSPECTIVE EXAMINATION OF THE K/ICA RATIO AS A PREDICTOR FOR MORTALITY IN SEVERE HEMORRHAGE.

Background: Patients receiving massive transfusion protocol (MTP) are at risk for posttransfusion hypocalcemia and hyperkalemia. Previous retrospective analysis has suggested the potassium/ionized calcium (K/iCa) ratio as a prognostic indicator of mortality. This prospective study sought to validate the value of the K/iCa ratio as a predictor for mortality in patients receiving MTP. Methods: This was a prospective analysis of adult trauma patients who underwent MTP activation from May 2019 to March 2021 at an urban level 1 trauma center. Serum potassium and iCa levels within 0 to 1 h of MTP initiation were used to obtain K/iCa. Receiver operator characteristic curve analysis assessed predictive capacity of K/iCa on mortality. Kaplan-Meier survival analysis and Cox regression examined the effect of K/iCa ratio on survival. Results: A total of 110 of 300 MTP activation patients met inclusion criteria. Overall mortality rate was 31.8%. No significant differences between the elevated K/iCa and lower K/iCa groups were found for prehospital or emergency department initial vitals, shock index, or injury severity. However, nonsurvivors had a significantly higher median K/iCa ratio compared with those who survived ( P < 0.01). Multivariable logistic regression revealed the total number of blood products to be significantly associated with elevated K/iCa (odds ratio, 1.02; 95% CI, 1.01-1.04; P = 0.01). The Kaplan Meier survival curve demonstrated a significantly increased rate of survival for those with an elevated K/iCa ratio ( P < 0.01). Multivariable Cox regression adjusted for confounders showed a significant association between K/iCa and mortality (Hazard Ratio, 4.12; 95% CI, 1.89-8.96; P < 0.001). Conclusion: This evidence further highlights the importance of the K/iCa ratio in predicting mortality among trauma patients receiving MTP. Furthermore, it demonstrates that posttransfusion K levels along with iCa levels should be carefully monitored in the MTP setting. Level of Evidence: Level II. Study Type: Prognostic/epidemiological.