Mean Initial Systolic Blood Pressure Research Articles

Impact of Diet and Lifestyle Modification and Weight Reduction on Essential Hypertension

Objectives: This study was to assess the impact of diet and lifestyle modification with weight reduction on blood pressure in patients with essential hypertension and to impart awareness regarding the importance of dietary modifications, physical exercise, and weight reduction in controlling or reversing high blood pressure and prevention of end-organ damage. Methods: This was a prospective observational study among overweight or obese hypertensives. We included 60 consecutive patients, who after sticking to the diet and lifestyle advice achieved weight reduction. They all were overweight, or had a history of weight gain, and had hypertension, or were newly diagnosed to have persistent hypertension. They were motivated to achieve weight reduction and educated about healthy eating habits using diet charts and tips for lifestyle modifications. Sixty such consecutive subjects, without any secondary causes for hypertension, and who complied with the diet and lifestyle advised, and thus achieved weight reduction only were subjected to statistical analysis. Those who did not achieve weight reduction were not taken for analysis Results: 90 % of the subjects had their BMI above normal and the remaining 10% of subjects had an upper range of normal BMI, but all of them gave a history of weight gain. The majority of the subjects were having faulty dietary habits with increased carbohydrate intake as the primary reason for weight gain, besides having inadequate vegetables, fruits and protein intake, along with 15% consuming junk food on a daily basis. After lifestyle intervention, weight reduction was achieved in all the subjects studied, and there was a significant reduction in both systolic and diastolic blood pressures with the weight loss achieved, and it was statistically significant. The association of decrease in SBP with a decrease in weight was significant with a p-value of <0.001. The mean initial systolic blood pressure was 154.13 mmHg (SD 13.31), and the follow up mean was 137.33 mmHg (SD 12.87). The mean decrease in SBP was 16.8mmHg, and the mean change in weight was 9.4 Kg. Most of the hypertensives had their drug number or dose decreased and some of them had their drugs stopped completely. Conclusions: Educating the subjects on balanced diet with restriction of carbohydrates with increased intake of vegetables, adequate fruits, ensuring adequate protein and adequate water intake was the key intervention. The results of the study strongly pointed towards the inevitable role diet, lifestyle and weight reduction had on the achievement of blood pressure control and even reversal of hypertension. Faulty dietary habits with excessive calorie intake, decreased vegetables and fruits, low physical activity and sedentary nature of work contributed to weight gain. Both systolic and diastolic BP decreased on weight reduction implying thereby weight gain as the primary cause for both. Awareness regarding the disease and its complications was very low. In addition, dietary malpractices were detected and halted, and this reinforced the positive results. It also had a favorable impact on the comorbidities they suffered from.

Recent advances in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage is a technology that is increasingly being utilized in the combat casualty setting. Its use in the resource restricted environment holds potential to improve hemorrhage control, decrease blood product utilization, decrease morbidity, and improve combat mortality. The objective of this report is to present the single largest series of REBOA use on severely injured combat casualties. Over an 18-month period, austere surgical teams comprised of coalition partners provided initial damage control resuscitation (DCR) and surgical stabilization for over 2,300 combat casualties prior to transferring patients to the next level of trauma care. Twenty patients presented with injuries from explosion and gunshot wounds with mean initial heart rate of 129 bpm and mean initial systolic blood pressure of 71 mm Hg. Femoral cutdowns were used in six patients. Aortic occlusion was achieved with REBOA catheter placement in Zone 1 (n = 17) and Zone 3 (n = 2). Systolic blood pressure increased an average of 56 mm Hg with aortic occlusion. There were no access related site complications. All patients survived transport to the next level of care. The majority of blood products transfused in this cohort were whole blood, largely supported by emergent blood drives. This series demonstrates the potential for REBOA as a lifesaving technique for the patient who presents with hemodynamic instability and noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta allows austere surgical teams to rapidly stabilize severely injured combat casualties, expand capability, and provide enhanced DCR while minimizing personnel, resources, and blood product utilization. The use of "whole blood only" strategy for DCR shows potential to be superior to traditional component therapy, and when combined with "proactive" REBOA utilization, provides significant improvements in hemodynamics and hemorrhage control. Case series, level V.

National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma

Lower extremity injury is common in trauma patients; however, the influence of arterial injury on devastating patient and limb outcomes can be confounded by the presence and physiological derangement of concomitant head or thoracoabdominal injuries. We analyzed isolated lower extremity injuries with an arterial component. Our aim was to elucidate factors associated with mortality and limb loss in this selected population. We reviewed trauma incidents from the National Trauma Data Bank (2002-2006) containing isolated lower extremity injury codes and a specified infrainguinal arterial injury. Demographics, injury patterns, clinical characteristics, and adverse outcomes (death, amputation) during initial hospitalization were collected. Multivariate logistic regression was used to identify risk factors for limb loss. There were 651 isolated infrainguinal arterial injuries. Death (18) and early limb loss (42) were studied by mechanism (penetrating, n = 431; blunt, n = 220). Half of the deaths involved injury to the common femoral artery (CFA), and over 80% had injury to the CFA or superficial femoral artery (SFA). Death was three times as frequent in the CFA/SFA than in the popliteal/tibial injuries (P = .02). Penetrating injuries were present in almost 80% of deaths, and most of these were gunshot wounds. Patients who died had mean initial systolic blood pressure of 59.7 mm Hg, and almost 40% had no blood pressure on arrival. Mean initial Glasgow Coma Score was 4.5, and almost 80% arrived with a Glasgow Coma Score of 3 despite the absence of head injury. Twenty-seven above- and 15 below-the-knee amputations were performed. The popliteal artery was injured in half of the amputations, with injury isolated to the popliteal or tibial arteries in about three-quarters. Amputation was twice as frequent in popliteal/tibial than CFA/SFA injury (P = .03) and twice as frequent in blunt than penetrating injury (P = .05). Multiple arterial injuries (odds ratio, 5.2; 95% confidence interval, 1.7-15.6; P = .003), and fracture (odds ratio, 2.2; 95% confidence interval, 1.1-4.2; P = .02) independently predicted amputation, while the presence of nerve injury and soft tissue disruption did not. Isolated lower extremity trauma with vascular injury has a nearly 10% rate of mortality or limb loss. Mortality is associated with penetrating mechanism and early shock, likely resulting from prehospital proximal arterial hemorrhage. In contrast, early limb loss is more common with blunt distal vascular injury, especially to the popliteal and tibial arteries. Neither nerve nor soft tissue injury predicted limb loss but may result in delayed amputations not captured in this acute outcomes dataset.

103: CLUE: A Comparative Effectiveness Trial of Nicardipine Versus Labetalol Use In the Emergency Department

103: CLUE: A Comparative Effectiveness Trial of Nicardipine Versus Labetalol Use In the Emergency Department

Active Intravascular Rewarming for Hypothermia Associated with Traumatic Injury: Early Experience with a New Technique

Hypothermia is a significant contributor to mortality in severely injured patients. Rewarming is an enormous challenge, especially in those who require operative or angiographic intervention. In this patient population, external warming methods are only capable of reducing further heat loss, whereas active rewarming adds heat to the body's core but is invasive. This article analyzes our initial experience with a minimally invasive, continuous, automated, and easily portable intravascular rewarming technique using the Alsius Corporation's CoolGard system. The records of 11 hypothermic critically injured patients presenting to our level 1 trauma center over a 6-month period were reviewed. The patients' mean age was 39 ± 22 years, 7 (64%) were male, and 7 (64%) had blunt mechanisms of injury. The mean injury severity score was 40 ± 16, and the mean initial systolic blood pressure was 91 ± 60 mm Hg. The mean core temperature at the initiation of rewarming was 33.6 ± 1.0°C, and the mean rewarming rate was 1.5 ± 1.0°C/h. Six patients died (55%), two of acute exsanguination and four of unsurvivable traumatic brain injuries. One patient developed a deep vein thrombosis at the femoral catheter site and experienced a nonfatal pulmonary embolus. Our experience demonstrates that active intravascular balloon-catheter rewarming represents a practical, automated technique for the immediate and continuous treatment of hypothermia in all phases of the acute care of trauma patients.

Active Intravascular Rewarming for Hypothermia Associated with Traumatic Injury: Early Experience with a New Technique

Hypothermia is a significant contributor to mortality in severely injured patients. Rewarming is an enormous challenge, especially in those who require operative or angiographic intervention. In this patient population, external warming methods are only capable of reducing further heat loss, whereas active rewarming adds heat to the body's core but is invasive. This article analyzes our initial experience with a minimally invasive, continuous, automated, and easily portable intravascular rewarming technique using the Alsius Corporation's CoolGard system. The records of 11 hypothermic critically injured patients presenting to our level 1 trauma center over a 6-month period were reviewed. The patients' mean age was 39 ± 22 years, 7 (64%) were male, and 7 (64%) had blunt mechanisms of injury. The mean injury severity score was 40 ± 16, and the mean initial systolic blood pressure was 91 ± 60 mm Hg. The mean core temperature at the initiation of rewarming was 33.6 ± 1.0°C, and the mean rewarming rate was 1.5 ± 1.0°C/h. Six patients died (55%), two of acute exsanguination and four of unsurvivable traumatic brain injuries. One patient developed a deep vein thrombosis at the femoral catheter site and experienced a nonfatal pulmonary embolus. Our experience demonstrates that active intravascular balloon-catheter rewarming represents a practical, automated technique for the immediate and continuous treatment of hypothermia in all phases of the acute care of trauma patients.

Limb salvage and outcomes among patients with traumatic popliteal vascular injury: An analysis of the National Trauma Data Bank

Popliteal arterial trauma carries the greatest risk of limb loss of any peripheral vascular injury. The purpose of this study was to analyze outcomes after popliteal arterial injuries and identify factors contributing to disability. A retrospective analysis was conducted of prospectively collected trauma data from the National Trauma Data Bank (NTDB). We studied all patients with popliteal arterial injury in terms of demographics, injury patterns, interventions, limb salvage, resource utilization, and outcomes. We identified 1395 popliteal arterial injuries among the 1,130,000 patients in the NTDB, for an incidence <0.2%. The patients were 82% male, with a mean age of 33 years, and they presented with a mean initial systolic blood pressure of 124 mm Hg, base deficit -4.6, injury severity score of 11.8, and an extremity abbreviated injury score of 2.6. The mechanism was blunt in 61% and penetrating in 39%, and significant baseline demographic differences existed between the two groups. Associated ipsilateral lower-extremity trauma included combined popliteal arterial and venous (AV) injuries, fractures and dislocations, and major nerve disruptions. Fasciotomies were performed in 49%, complex soft tissue repairs in 24%, and amputations in 14.5%. The overall mean hospital and intensive care unit lengths of stay were 16.9 and 5.9 days. The mean functional independence measure for locomotion was 2.8, but was significantly lower for patients with blunt trauma. In-hospital mortality was 4.5% and did not significantly differ by mechanism. Amputation rates were 15% with combined AV injuries, 21% for associated nerve injuries, 12% for major soft tissue disruptions, and 21% for femur, 12% for knee, and 20% for tibia-fibula fractures or dislocations. Among the 312 patients with combined AV injuries, those with blunt mechanism had a significantly higher amputation rate than those with penetrating injury (27% vs 9%, P < .001). Adjusting for age, gender, mechanism, and overall physiologic impact of injuries sustained, independent predictors of amputation in logistic regression analysis of the entire cohort included fracture (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.4 to 4.1), complex soft tissue injury (OR, 1.9; 95% CI, 1.2 to 3.0), nerve injury (OR, 1.7; 95% CI, 1.1 to 2.8), and extremity abbreviated injury score (OR, 1.6; 95% CI, 1.2 to 2.2). Popliteal vascular injury remains an uncommon but challenging clinical entity associated with significant rates of limb loss, functional disability, and mortality. Blunt vs penetrating mechanism and associated musculoskeletal injuries generally involve longer hospital stays, worse functional outcomes, and twice the amputation rate.

DIAGNOSTIC ACCURACY OF LEFT VENTRICULAR FUNCTION FOR IDENTIFYING SEPSIS AMONG EMERGENCY DEPARTMENT PATIENTS WITH NONTRAUMATIC SYMPTOMATIC UNDIFFERENTIATED HYPOTENSION

The hypothesis of this study states that in emergency department (ED) patients with non-traumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with non-traumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were non-trauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohen's kappa for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57+/-16.7 years, 59% were male, and the mean initial systolic blood pressure was 83+/-11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of kappa=0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with non-traumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.

Operational performance of validated physiologic scoring systems for predicting in-hospital mortality among critically ill emergency department patients*

New Simplified Acute Physiology Score (SAPS) II, Morbidity Probability Model at admission (MPM0 II), and Logistic Organ Dysfunction System (LODS) have all demonstrated high accuracy for predicting mortality in intensive care unit populations. We tested the prognostic accuracy of these instruments for predicting mortality among a cohort of critically ill emergency department patients. Secondary analysis of a randomized controlled trial. Urban, tertiary emergency department, census >100,000. Nontrauma emergency department patients admitted to an intensive care unit, aged >17 yrs, with initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and with agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. Emergency department variables needed for calculation of each scoring system were prospectively collected, and published formulas were used to calculate the probability of in-hospital death for each scoring system. The main outcome was actual in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of each scoring system. Ninety-one of 202 patients (45%) were included. The mean age was 56 +/- 16 yrs, 42% were female, the mean initial systolic blood pressure was 84 +/- 13 mm Hg, and the average length of stay in the emergency department was 4.2 +/- 2.0 hrs. The in-hospital mortality rate was 21%. The area under the receiver operating characteristic curve for calculated probability of in-hospital mortality for SAPS II was 0.72 (95% confidence interval, 0.57-0.87), for MPM0 II 0.69 (95% confidence interval, 0.54-0.84), and for LODS 0.60 (95% confidence interval, 0.45-0.76). Using variables available in the emergency department, three previously validated intensive care unit scoring systems demonstrated moderate accuracy for predicting in-hospital mortality.

Validated physiologic scoring systems are inadequate for predicting in-hospital mortality among critically ill emergency department patients

Study objectives: The New Simplified Acute Physiology Score (SAPS II), Morbidity Probability Models (MPM II), and Logistic Organ Dysfunction System (LODS) have all demonstrated high accuracy (>0.80 for area under the receiver operating characteristic [ROC] curve) for predicting mortality in ICU populations. We examined the prognostic utility of these 3 instruments in a cohort of prospectively studied critically ill emergency department (ED) patients. Methods: We performed a secondary analysis of 190 patients enrolled in a randomized controlled trial from January 2002 to October 2003. Inclusion criteria were age older than 18 years, no history of trauma, arterial hypotension (systolic blood pressure Results: Ninety-one (47%) of 190 patients were admitted to the ICU and analyzed in this study. The mean age was 56±16 years, 42% were female patients, the mean initial systolic blood pressure was 84±13 mm Hg, and the average length of stay in the ED was 4.2±2.0 hours. The inhospital mortality rate was 21%. The average SAPS II score was 40±14 points, the average LODS score was 5±3 points, and the average MPM II (using MPM 0 ) score was −1.058±1.242. The area under the ROC curve for calculated probability of inhospital mortality for SAPS II was 0.72 (95% confidence interval [CI] 0.57 to 0.87), for MPM 0 was 0.69 (95% CI 0.54 to 0.84), and for LODS was 0.60 (95% CI 0.45 to 0.76). Conclusion: Using variables available in the ED, 3 previously validated ICU scoring systems (SAPS II, MPM II, and LODS) demonstrated moderate accuracy. The lower limits of the CIs do not exclude poor prognostic accuracy (area under the curve

23. Ambulance Sphygmomanometer Accuracy: Can It Affect Triage to the Trauma Center?

Objectives: To determine the accuracy of sphygmomanometers (SPHYGs) from a metropolitan EMS system and quantitate the mis-triage of adult blunt trauma patients based on erroneous systolic blood pressure (SBP) readings.Methods-A: A cross-sectional, convenient sample of 150 SPHYGs was checked for accuracy using industry standards. Mean high and low deviations were calculated at 90 mmHg.Methods-B: Retrospectively, a frequency distribution of the initial SBPs of all blunt trauma patients, age ≥21, seen in 1994 was plotted to characterize our study population. The numbers of patients potentially over- or under-triaged were identified when their reported SBP was corrected for using the mean high and low deviation plus 2 SDs.Results-A: Overall, 25.3% of the SPHYGs were inaccurate. At 90 mmHg, 28.0% (42/150) were inaccurate with 16.7% (7/42) high by 4.6±1.5 mmHg and 81.0% (34/42) low by 6.2±4.2 mmHg; one was inoperable.Results-B: 1,005 adult blunt trauma patients were evaluated; 61 were eliminated: 35 had initial SBPs of 0 mmHg and 26 had no SBP recorded (n = 944). The mean initial SBP was 138 ±30mmHg, and 3.8% (36/944) of the patients had SBPs &lt;90 mmHg. Potentially, 2.0% (19/944) of the patients were undertriaged (initial erroneously high SBP reading 90–98 mmHg) and 2.5% (24/944) over-triaged (initial erroneously low SBP reading 74–90 mmHg).

HEAD CT SCANNING VERSUS URGENT EXPLORATION IN THE HYPOTENSIVE BLUNT TRAUMA PATIENT

In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 +/- 26 mm Hg, and the mean Trauma Score was 8 +/- 5.8. Serious head injury (AIS head > or = 3) was present in 40% (293 of 734). Of 734 patients studied, 9.4% (69 of 734) died in the emergency department. Head CT scanning was performed on 47% (344 of 734) and produced positive results for 26% (202 of 734). Emergency craniotomy for intracranial hemorrhage was performed on 2.5% (18 of 734) (ten subdurals, three epidurals, and five other intracranial hemorrhages). Twenty-one percent (154 of 734) underwent urgent laparotomy, thoracotomy, or both. Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.

The Effect of Anti-Shock Garments on Prehospital Survival: The Need for Controlled Clinical Trials

AbstractThere exists strong sentiment, among emergency medical personnel and physicians alike, that the pneumatic anti-shock garment (PASG) “saves lives.” As a result, controlled studies have been criticized as the “withholding of important therapy.” The purpose of this presentation is to confirm the need for controlled clinical trials of the PASG. Despite an early report that the PASG offered no advantage in terms of the presenting emergency center Trauma Score (TS), similar disparagements have continued, particularly because survival data were not discussed. The present report is a pilot analysis of the effect of the PASG on the prehospital survival of patients arriving at an urban trauma center in the United States. In the study, sixty-eight patients were assigned randomly to control and PASG groups in a prospective investigation involving injured patients with systemic hypotension. The 32 control patients, whose mean initial systolic blood pressure (BP) was 59 ± 32 mm Hg, and the 36 PASG-treated patients, whose mean initial BP was 55 ± 31 mm Hg, were found to be well matched for age, sex, type and location of injuries, initial field TS; response, field management, and transport times; and the total amount of intravenous crystalloid infused. The results demonstrated no significant difference between the control and PASG-treated groups in terms of those pronounced dead on arrival at the trauma center (9/32 vs. 10/36). Further studies are therefore justified to determine how the PASG affects the long-term morbidity and mortality of injury victims, particularly those within certain sub-groups such as penetrating abdominal versus those with penetrating thoracic injuries. This report reaffirms the need for early responsible, scientific scrutiny of prehospital interventions.