Non-traumatic Patients Research Articles

Hazard Ratio of 90-Day Mortality in ICU Patients with Abdominal Injuries Compared with Head Injuries.

Despite advances in the treatment of abdominal injuries in patients with trauma, it remains a major public health problem worldwide. Evaluation of hazard ratio (HR) of 90-day mortality in intensive care unit (ICU) patients with abdominal injuries compare with head injuries in trauma patients and non-trauma surgical ICU patients. This single-center, prospective cohort study was conducted on 400 patients admitted to the ICU between 2018 and 2019 due to trauma or surgery in Hamadan, Iran. The main outcome was mortality at 90-day after ICU admission. Cox proportional hazards models were used to determine the HR and 95% confidence interval (CI) for 90-day mortality. The 90-day mortality was 21.9% in abdominal injuries patients. According to multivariate Cox regression, the expected hazard mortality was 2.758 times higher in patients with abdominal injuries compared to non-trauma patients (HR: 2.758, 95% CI: 1.077-7.063, P=0.034). About more than 50% of all deaths in the abdominal and head trauma groups occurred within 20 days after admission. Mean time to death was 27.85±20.1, 30.27±18.22 and 31.43±26.24 days for abdominal-trauma, surgical-ICU, and head-trauma groups, respectively. Difficulty in accurate diagnosis due to the complex physiological variability of abdominal trauma, less obvious clinical symptoms in blunt abdominal injuries, multi-organ dysfunction in abdominal injuries, failure to provide timely acute care, as well as different treatment methods all account for the high 90-day mortality rate in abdominal-trauma patients. Therefore, these patients need a multidisciplinary team to care for them both in the ICU and afterwards in the general ward.

A retrospective HEART risk score comparation of acute non-traumatic chest pain patients in an emergency department in Spain

Non traumatic chest pain is the second most common cause of attention at the Emergency Departments (ED). The objective is to compare the effectiveness of HEART risk score and the risk of having a Major Adverse Cardiovascular Event (MACE) during the following 6 weeks in ‘Acute Non-traumatic Chest Pain’ (ANTCP) patients of an ED in Lleida (Spain). The ANTCP patient cohort was defined using medical data from January 2015 to January 2016. A retrospective study was performed among 300 ANTCP patients. Diagnostic accuracy to predict MACE, HEART risk score effectiveness and patient risk stratification were analysed on the ANTCP Cohort. HEART risk score was conducted on ANTCP Cohort data and patients were stratified as low-risk (n = 116, 38.7%), moderate-risk (n = 164, 54.7%) and high-risk (n = 20, 6.7%); differently from the assessment performed by 'Current Emergency Department Guidelines’ (CEDG) on the same patients: low risk and discharge (n = 56, 18.7%), medium risk and need of complementary tests (n = 137, 45.7%) and high risk and hospital admission (n = 107, 35.7%).The incidence of MACE was 2.5%, 20.7% and 100% in low, moderate and high-risk, respectively. Discrimination and accuracy indexes were moderate (AUC = 0.73, 95% confidence interval: 0.67–0.80). Clustering moderate-high risk groups by MACE incidence showed an 89.5% of sensitivity. Data obtained from this study suggests that HEART risk score stratified better ‘acute non-traumatic chest pain’ (ANTCP) patients in an Emergency Department (ED) compared with ‘Current Emergency Department Guidelines’ (CEDG) at the Hospital Universitari Arnau de Vilanova (HUAV). HEART score would reduce the number of subsequent consultations, unnecessary admissions and complementary tests.Trial registration: Retrospectively registered.

Changes in peripheral arterial blood pressure after resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic cardiac arrest patients

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) may be an adjunct treatment to cardiopulmonary resuscitation (CPR). Aortic occlusion may increase aortic pressure and increase the coronary perfusion pressure and the cerebral blood flow. Peripheral arterial blood pressure is often measured during or after CPR, however, changes in peripheral blood pressure after aortic occlusion is insufficiently described. This study aimed to assess changes in peripheral arterial blood pressure after REBOA in patients with out of hospital cardiac arrest.MethodsA prospective observational study performed at the helicopter emergency medical service in Trondheim (Norway). Eligible patients received REBOA as adjunct treatment to advanced cardiac life support. Peripheral invasive arterial blood pressure and end-tidal CO2 (EtCO2) was measured before and after aortic occlusion. Differences in arterial blood pressures and EtCO2 before and after occlusion was analysed with Wilcoxon Signed Rank test.ResultsFive patients were included to the study. The median REBOA procedural time was 11 min and median time from dispatch to aortic occlusion was 50 min. Two patients achieved return of spontaneous circulation. EtCO2 increased significantly 60 s after occlusion, by a mean of 1.16 kPa (p = 0.043). Before occlusion the arterial pressure in the compression phase were 43.2 (range 12–112) mmHg, the mean pressure 18.6 (range 4–27) mmHg and pressure in the relaxation phase 7.8 (range − 7 – 22) mmHg. After aortic occlusion the corresponding pressures were 114.8 (range 23–241) mmHg, 44.6 (range 15–87) mmHg and 14.8 (range 0–29) mmHg. The arterial pressures were significant different in the compression phase and as mean pressure (p = 0.043 and p = 0.043, respectively) and not significant in the relaxation phase (p = 0.223).ConclusionThis study is, to our knowledge, the first to assess the peripheral invasive arterial blood pressure response to aortic occlusion during CPR in the pre-hospital setting. REBOA application during CPR is associated with a significantly increase in peripheral artery pressures. This likely indicates improved central aortic blood pressure and warrants studies with simultaneous peripheral and central blood pressure measurement during aortic occlusion.Trial registrationThe study is registered in ClinicalTrials.gov (NCT03534011).

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial

To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30days (DF/CF-ICU-30) using multivariate linear regression. A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0years vs 40.5 ± 17.0years [p < 0.001]). Mean DF/CF-ICU-30days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Abstract 12185: Impact of Cardiac Arrest Centers on the Survival of Nontraumatic Out-of-Hospital Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Introduction: The role of cardiac arrest centers (CAC) in out-of-hospital cardiac arrest (OHCA) is uncertain, especially since CACs are inconsistently defined. This study seeks to address knowledge gaps by assessing the impact of CACs on nontraumatic OHCA patients as a whole and among specific subgroups. Methods: In this review, Medline, Embase, and Cochrane CENTRAL were searched from inception to 9 March 2021. Studies were included if they compared CAC vs non-CAC among adult patients with nontraumatic OHCA. CACs were explicitly named by study authors and were capable of appropriate interventions. Data abstraction and quality assessment were independently conducted by two authors, and a third author resolved discrepancies. Main outcomes were survival and survival with favorable neurological outcome at hospital discharge or at 30 days. Meta-analyses were performed for adjusted (aOR) and crude (OR) odds ratios. Sensitivity analyses were conducted for wider definitions of CAC such as high volume centers or improved post-resuscitation care, and subgroups analysed to account for heterogeneity. Results: The search yielded 4544 articles, and 36 were included for analysis. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR = 1.88, 95% CI 1.53 to 2.31), even when including high volume centers (aOR = 1.68, 95% CI 1.30 to 2.16), or when including improved care centers (aOR = 2.16, 95% CI 1.76 to 2.64) as CACs. Survival significantly increased with treatment at CAC (aOR = 1.92, 95% CI 1.59 to 2.31), even when including high volume centers (aOR = 1.74, 95% CI 1.38 to 2.18), or when including improved care centers (aOR = 1.97, 95% CI 1.71 to 2.26) as CACs. The effect on favorable neurological outcome was more pronounced among patients with shockable rhythm (p = 0.03) and on survival among patients without prehospital ROSC (p = 0.005). Findings were robust to sensitivity analyses, with no publication bias detected. Conclusion: CACs improved survival and neurological outcomes for nontraumatic OHCA patients despite varying definitions of CAC. Patients with shockable rhythms and without prehospital ROSC appeared to yield greater benefit from CACs. Evidence for bypassing hospitals or inter-hospital transfer remains inconclusive.

Abstract 9056: The Association Between Thoracic Injuries Due to Chest Compression and Short-Term Prognosis in Patients With Non-traumatic Out-of-Hospital Cardiac Arrest

Background: The current guidelines emphasize that high-quality chest compression is essential for improving the survival in out-of-hospital cardiac arrest (OHCA) patients. However, it may lead to thoracic injuries which is a potential factor of poor prognosis. Method: Between June 2017 to July 2019, we collected Utstein-style data on 384 consecutive adult patients with non-traumatic OHCA who were transferred to our hospital. Full-body CT scan was performed and thoracic injuries were defined as rib fracture, sternum fracture, hemorrhagic pleural effusion, pneumothorax, sternum posterior bleeding, mediastinal hematoma, or mediastinal emphysema. We identified the predictors for thoracic injuries and evaluated the relationship between thoracic injuries and prognosis. Results: Patients with thoracic injuries (Group-T) were 234 (76%). The duration of chest compression in Group-T was 43 min, which was significantly longer than that in patients without thoracic injuries (Group-N, 32 min, p&lt;0.001). ROC curve analysis identified a duration of chest compression of 35 minutes as the optimal cut off for predicting thoracic injuries (area under the curve 0.73). Multivariate analysis revealed that age (OR: 1.03, 95%CI: 1.01-1.05, p=0.005) and duration of chest compression (OR: 1.07, 95%CI: 1.04-1.09, p&lt;0.001) were independent predictors of thoracic injuries. The rate of obtaining return of spontaneous circulation (ROSC), 30-day survival and favorable neurologic outcome were larger in Group-N than Group-T. In patients with achieving ROSC, Kaplan-Meier curves showed a significantly higher cumulative survival rates in Group-N compared to that in Group-T during follow-up of 30 days (Log-rank test p=0.009). Conclusion: Age and duration of chest compression were independent predictors for thoracic injuries due to chest compression in non-traumatic OHCA patients. Moreover, the presence of thoracic injuries was associated with poor short-term prognosis.

Abstract 13761: Does Targeted Temperature Management Modify the Association Between Increasing Epinephrine Dose and Survival Outcomes Following Out-of-Hospital Cardiac Arrest?

Introduction: Epinephrine (EPI) improves return of circulation after out of hospital cardiac arrest (OHCA). These beneficial cardiac effects are not accompanied by improved neurological survival possibly due to EPI induced microvascular effects and critical brain ischemia. We hypothesized that these dose-dependent adverse EPI effects may be mitigated by targeted temperature management (TTM) such that the relative benefit of TTM is greater at higher EPI doses. Methods: This was a retrospective cohort study of adult non-traumatic OHCA patients in Seattle and King County, Washington from 2008-2018, who were unconscious at hospital admission. We used logistic regression to assess the relationship among EPI dose, TTM, and survival to hospital discharge, and survival with favorable neurological status (Cerebral Performance Category (CPC) 1 or 2). The model evaluated whether TTM modified the association of increasing EPI dose using an interaction term between TTM and EPI dose. Results were stratified by initial shockable vs non-shockable rhythm. Results: Of 5254 eligible patients, the median EPI dose was 2.0 mg (IQR 1.0 - 3.0); 3052 (58%) received TTM. In all, 2177 (41%) survived to discharge, and 1889 (36%) survived with CPC 1-2. Increasing dose of EPI was associated with a decreasing likelihood of survival (OR 0.58, [95% CI 0.55-0.61] for each additional mg of EPI) and CPC 1-2 (OR 0.56, [0.53-0.59]). The dose-dependent EPI association was modified by TTM. After adjustment for Utstein covariates, for each additional mg of EPI, TTM was associated with a relative stepwise improvement in odds of survival (interaction OR 1.35, [1.23, 1.49]) and CPC 1-2 (OR 1.34, [1.21, 1.50]) (Figure). This interaction was consistent among shockable and non-shockable OHCA (Figure). Conclusions: We observed an interaction between TTM and EPI dose such that the beneficial association of TTM increased with increasing EPI dose, suggesting TTM may attenuate the adverse effects of higher dose EPI.

Abstract 10100: Early Prediction of Neurological Outcome at 30 Days After Return of Spontaneous Circulation From Out-of-Hospital Cardiac Arrest

Aim: To develop and validate a model for early prediction of neurological outcomes in non-traumatic out-hospital cardiac arrest (OHCA) patients. Methods: We analyzed the data of adult non-traumatic cardiac arrest patients who experienced return of spontaneous circulation (ROSC) and were admitted to the intensive care unit between January 2013 and December 2017 from the database of a multicenter registry. We allocated 1329 patients who were admitted from 2013 to 2015 to the derivation set and 1025 patients admitted from 2016 to 2017 to the validation set. The primary outcome was the dichotomized Cerebral Performance Category at 30 days. We developed 2 models: model 1 including variables except for laboratory data and model 2 including all variables with laboratory data immediately available after ROSC. Logistic regression with least absolute shrinkage and selection operator regularization was used for model development. The C-statistics for discrimination, the prognostic ability, and calibration of the prediction model were assessed in the validation set. The reclassification of model 2 compared to model 1 was also evaluated by continuous net reclassification index (NRI). Results: The C-statistics [95% confidence intervals] of model 2 and 1 in validation set was 0.940 [0.921-0.959] and 0.935 [0.914-0.957], respectively (Figure 1). The calibration plot showed that both models were well-calibrated to observed neurological outcomes (Figure 2). The model 2 reclassified patients better than the model 1 (NRI: 0.663, p &lt; 0.001). A web-based calculator based on these models was developed that allows clinicians to input the predictor variables needed for the probability of good or poor neurological outcomes (https://pcas-prediction.shinyapps.io/pcas_lasso/). Conclusion: The prediction tool including detailed in-hospital information showed good performance to predict neurological outcomes at 30 days in patients with ROSC after OHCA.

Causes of death following discharge after trauma in North Carolina.

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission. This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis. Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days). After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge. Prognostic and Epidemiologic, Level IV.

Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study

BackgroundWhile there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol.MethodsAll CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]).ResultsThe any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients.ConclusionOur simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Patterns of paediatric massive blood transfusion protocol use in trauma and non-trauma patients.

Massive blood transfusion is infrequently required by children but can be a lifesaving intervention for haemorrhage or coagulopathy. Product volumes and ratios administered during the initiation of paediatric massive blood transfusion protocol (MBTP) are highly variable and the optimal component ratio is unknown. We performed a single-centre retrospective chart review of patients (<20 years) who received MBTP activation from August 2012 through January 2018. Logistic regression was used to determine the association between MBTP use characteristics (including blood product type and volume transfused, extracorporeal membrane oxygenation [ECMO] support, and cardiac arrest occurrence) and 24-h mortality. "Low" product ratio was defined as a ratio of plasma or platelets to red blood cells (RBCs) of <1:2 and "high" as ≥1:2. Ninety-eight MBTPs were activated for 89 patients (range 1-4 per patient). The most common underlying diagnoses were congenital heart disease (CHD, n=28, 31.5%), followed by cardiopulmonary disease, and trauma. CHD patients required the greatest volume of RBCs (226.3ml/kg, 95%CI [160.0, 292.7], p=0.002) and platelets (46.7ml/kg, 95%CI [33.2, 60.2], p < 0.001). A "low" product ratio was more common for the MBTP, with its incidence similar among the underlying diagnoses. An MBTP developed for trauma patients can be applied to non-trauma patients but standard MBTP components may not be optimal for all children. These findings show that underlying patient diagnoses may be a factor when designing an MBTP for a heterogeneous paediatric population.

Clinical Diagnosis and Per-Operative Findings Non-Traumatic emergency Laparotomy-A Study of 200 Cases

Introduction: In surgical wards, most of the patients of emergency admission present with abdominal complaints, for which laparotomy is indicated in many cases. Sometimes the diagnosis is obvious and can be done by taking a detailed history and careful clinical examination. Objective: To assess the clinical evaluation of non-traumatic emergency laparotomy, a study of 200 cases. Materials and Methods: It is a prospective study. Two hundred cases of nontraumatic emergency laparotomy patients were studied in Dhaka Medical College Hospital during the period of July 2007 to June 2008. Limited investigations dictated by the clinical conditions were done. Plain X-ray abdomen was the most frequently used investigation alone with blood count, serum amylase and ultrasonogram of abdomen. Clinical diagnosis was made depending on clinical findings and the results of investigations. Results: In total, 200 cases of non-traumatic emergency laparotomy, 139(69.5%) were male and 61(30.5%) were female. Among the 200 patients age of them ranged from 12 to 75 years. Most of them were in the age group of 10 to 50 years of age. In acute appendicitis, pain followed by vomiting in 83.33 of cases, whereas in perforation of duodenal ulcer this incidence was only 14.28%.Pain and fever predominates 51.5% followed by severe abdominal pain 47%.The most common diagnosis of this series was acute appendicitis (48%), followed by duodenal ulcer perforation (24%). Ileal perforation (96) and largegut obstruction (5.5%) occupied third and fourth position respectively. Above study shows that males are more affected by acute non traumatic abdominal diseases and undergone laparotomy. Diagnostic accuracy in respect of clinical diagnosis was highest in case of perforated peptic ulcer (91.07%). In case of acute appendicitis, it was 87.5%. In case of intestinal obstruction, it was 88.88%. Conclusion: The inconsistency between clinical diagnosis and peroperative findings can be minimized with more meticulous ....

Clinical Predictors of Abnormal Head Computed Tomography Findings in Non-trauma Patients Presenting to a South African Emergency Department.

Background: Head computed tomography (head CT) examinations conducted at emergency departments (EDs) for non-trauma patients are expensive and expose patients to ionizing radiation. Identification of symptoms likely to yield abnormal head CT scans can reduce costs and prevent unnecessary patient irradiation. There is limited comprehensive data in the literature concerning the utilization of head CT in low- and middle-income countries (LMICs) EDs. Methods: A retrospective study of successive non-contrasted head CT scans from February 2017 through January 2018 performed on non-trauma ED patients aged 18 years and above without known pre-existing intracranial pathology was conducted. Univariate and multivariate logistic models were used to determine which presenting clinical features were likely to yield abnormal head CT findings. Clinical information was obtained from the history and physical examination findings entered on the requisition form by the ED clinicians and from previous head CT reports if present on the picture archiving and communication system (PACS). Results: A total of 396 consecutive patients who received head CT examinations had a median age of 49 years (IQR: 36-53), and 53.3% were male (n = 211/396). Of the head CT scans included, 73.5% of head CTs included were abnormal (n = 291/396). Age >61 years (aOR:1.54; 95%CI: 1.12-2.10), focal neurologic deficit (aOR: 2.46; 95%CI: 1.42-4.26), and loss of consciousness (aOR 2.82; 95%CI: 1.21-6.57) were the predictors of abnormal head CT findings. Conclusion: A head CT scan in a non-trauma patient presenting to an emergency department in a low-middle income country like South Africa is likely to yield abnormal findings if a patient presented with age above 61 years, loss of consciousness, or focal neurological deficit.

Risk factors for 2-year mortality in patients with prolonged disorders of consciousness: An international multicentre study.

Patients with prolonged disorders of consciousness (pDoC) have a high mortality rate due to medical complications. Because an accurate prognosis is essential for decision-making on patients' management, we analysed data from an international multicentre prospective cohort study to evaluate 2-year mortality rate and bedside predictors of mortality. We enrolled adult patients in prolonged vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS) after traumatic and nontraumatic brain injury within 3months postinjury. At enrolment, we collected demographic (age, sex), anamnestic (aetiology, time postinjury), clinical (Coma Recovery Scale-Revised [CRS-R], Disability Rating Scale, Nociception Coma Scale-Revised), and neurophysiologic (electroencephalogram [EEG], somatosensory evoked and event-related potentials) data. Patients were followed up to gather data on mortality up to 24months postinjury. Among 143 traumatic (n=55) and nontraumatic (n=88) patients (VS/UWS, n=68, 19 females; MCS, n=75, 22 females), 41 (28.7%) died within 24months postinjury. Mortality rate was higher in VS/UWS (42.6%) than in MCS (16%; p<0.001). Multivariate regression in VS/UWS showed that significant predictors of mortality were older age and lower CRS-R total score, whereas in MCS female sex and absence of alpha rhythm on EEG at study entry were significant predictors. This study demonstrated that a feasible multimodal assessment in the postacute phase can help clinicians to identify patients with pDoC at higher risk of mortality within 24months after brain injury. This evidence can help clinicians and patients' families to navigate the complex clinical decision-making process and promote an international standardization of prognostic procedures for patients with pDoC.

The Statewide Epidemiology of Mucormycosis Among Trauma Patients in Florida.

Mucormycosis is a rare angioinvasive infection caused by filamentous fungi with a high lethality among the immunocompromised. In healthy people, the innate immune system is sufficient to prevent infection. The exception to this is deep tissue exposure seen during trauma. The purpose of this study is to evaluate the epidemiology of mucormycosis using a statewide population-based data set. This is a retrospective cohort study of all hospital admissions for mucormycosis within the state of Florida from 1997 through the beginning of 2020. A distribution map was created to evaluate for geographic variation. Botanical growth zones, based on plant hardiness, used by state environmental agencies and landscapers were also used to detect possible patterns based on climate conditions throughout Florida. A multivariable regression analysis was performed to account for confounders and limit bias. A total of 1190 patients were identified for mucormycosis infection. Only 86 of these patients were admitted for trauma. Cutaneous infections were more prevalent among trauma patients while non-trauma patients had more pulmonary infections (P = .04). Trauma patients with infection tended to be younger and less likely to suffer from comorbidities such as immunosuppression (36% vs 46%, P = .07) and diabetes (22.1% vs 47.1%, P ≤ .0001) as compared to their non-trauma counterparts. Mortality was similar with 17.8% for non-trauma patients and 15.1% for traumatized patients (AOR .80 [.42, 1.52]). Length of stay was longer for trauma patients (37.3 vs 23.0, P < .0001). Infections were less prominent in plant hardiness Zone 9 and Zone 10 as compared to Zone 8 (AOR .71 [.61, .82]; AOR .54 [.46, .64], respectively). Trauma patients who develop infection from mucormycosis are at high risk of death despite being a younger and healthier population. Mucormycosis infections were primarily soft tissue based among trauma patients. These infections are more prevalent in colder regions within Florida.

707 Principles of Damage Control Surgery in Trauma and Beyond: Experience at A Tertiary Centre

Abstract Damage control surgery (DCS) is an abbreviated laparotomy used as a temporising measure in critically unwell patients who have limited physiological reserves to tolerate complex definitive surgeries. The aim of DCS is to address life-threatening haemorrhage and manage abdominal contamination. Following an abbreviated laparotomy, patients are continuously resuscitated in intensive care unit until physiological stability can be maintained for definitive surgeries. The role of DCS in the trauma setting is well-described; however, its principles can also be applied in General Surgery for a variety of indications such as mesenteric ischaemia, uncontrolled haemorrhage, and secondary peritonitis. Judicious selection of the non-trauma patient who will benefit from this strategy is paramount. We present two cases of a polytrauma patient (Patient A), and non-trauma patient with abdominal septic shock (Patient B) who underwent DCS at our tertiary centre. Patient A is a 49-year-old male involved in a road traffic accident who sustained multiple injuries including liver laceration, splenic laceration, and colonic injury. Intra-abdominal packing and repair of serosal tears were performed, with a re-look laparotomy 48 hours later -- no further bleeding or visceral injuries were identified. Patient B is a 51-year-old gentleman who re-presented in septic shock due to infected retroperitoneal collection following a bleeding duodenal ulcer, initially managed radiologically. A T tube was inserted into the duodenum with two abdominal drains at initial DCS. After thorough washout, a feeding jejunostomy was sited at the re-look laparotomy. 30-days mortality is 0% and both patients are under follow-up.

205 Arterial Doppler Ultrasound to Improve Detection of ROSC in Cardiac Arrest

Determination of the presence of a pulse is critical in the management of cardiac arrest (CA) patients. However, reports have demonstrated the inaccuracy of manual pulse detection. Additionally, Doppler ultrasound may be too sensitive for pulse detection and could detect flow without adequate blood pressure needed for perfusion. The purpose of this study is to assess the sensitivity, specificity, and accuracy of doppler femoral pulse detection in comparison to manual femoral pulse detection using an arterial line as the gold standard in CA patients. This is a prospective study of non-traumatic CA patients who occurred in a quarternary care emergency department (ED). All patients had an arterial line in place to serve as the gold standard for pulse detection. During a pulse check, the presence or absence of a femoral artery Doppler waveform and manual femoral pulse, as well as the systolic blood pressure (SBP) on the arterial line, were recorded simultaneously. Two physicians reviewed all Doppler waveform images to confirm presence or absence of a pulse. We calculated the sensitivity, specificity, and accuracy of both Doppler ultrasound and manual palpation for determining the presence of any pulse. We then calculated the same measurements using an arterial line SBP ≥60mmHg as consensus agreement believed this to be the minimum pressure indicating the presence of a pulse with an adequate perfusing blood pressure. We enrolled 46 patients and performed a total of 167 pulse checks. The sensitivity of Doppler ultrasound detection of a pulse at any blood pressure was 0.92 (95% CI: 0.87, 0.97) with a specificity of 0.98 (95% CI: 0.94, 1.00), and accuracy of 0.94 (95% CI: 0.89, 0.97). The sensitivity and specificity of manual palpation of a pulse was 0.36 (95% CI: 0.27, 0.44) and 0.90 (95% CI: 0.82, 1.00), respectively, with an accuracy of 0.53 (95% CI: 0.45, 0.60). When a SBP ≥60mmHg was used to indicate the presence of an adequate pulse, the sensitivity of Doppler ultrasound was 1.00 (95% CI: 1.00, 1.00), however the specificity was 0.55 (95% CI: 0.46, 0.64) with an accuracy 0.71 (95% CI: 0.63, 0.77), while manual palpation had a sensitivity of 0.45 (95% CI: 0.32, 0.58), with a specificity of 0.82 (95% CI: 0.74, 0.89 and an accuracy of 0.69 (95% CI: 0.6, 0.76). This study indicates that while accuracy of Doppler ultrasound for pulse detection is superior to manual palpation, the overall accuracies are similar when a SBP ≥60mmHg is used to indicate the presence of a pulse perfusing blood pressure. This study identifies the need to determine if doppler ultrasound waveforms can further distinguish between an adequately perfusing pulse and pseudo pulseless electrical activity.

Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review.

There is a lack of consensus regarding the role of investigations among patients presenting to the emergency department (ED) with recurrent seizures. The aim of this systematic review was to determine the frequency and utility of commonly requested investigations for nontrauma patients presenting to the ED with recurrent seizures. The MEDLINE, EMBASE, and Cochrane Library databases were searched (March 2021) for articles on this topic using search terms related to recurrent seizures, investigations, and the ED. The inclusion criteria required that articles include adult nontrauma patients presenting to the ED. Studies exclusively investigating first-episode seizures, trauma patients, and status epilepticus were excluded. Eligible studies were assessed for bias using the Newcastle-Ottawa scale. Results of studies were presented using proportions. There were six cohort studies included that contributed data from 36,595 patients. All six studies assessed at least one of our primary outcomes for computed tomography (CT) brain scans. The proportion of patients who underwent a head CT ranged from 13% to 42%. The rates of abnormal head CT findings ranged from 8% to 21%. One study reported on magnetic resonance imaging (MRI) and found it used infrequently in 0.79% of cases. The proportion and yield of nonneuroimaging investigations were not well evaluated in this patient population. Only one study reported on the utility of sodium levels or blood glucose results for this population and reported abnormalities in sodium levels for 19% of patients and abnormalities in glucose levels in 50% of patients. In this population, CT brain scans appeared to be performed uncommonly but with moderate rates of abnormal findings. In the absence of prolonged alteration of consciousness, a history of brain tumor, or positive neurologic findings, however, neuroimaging was of low yield. Given the heterogeneity and potential limitations of these studies, further research on this topic is required.

Efficacy and Safety of Whole Blood Transfusion in Non-Trauma Patients.

Whole blood (WB) transfusion for trauma patients with severe hemorrhage has demonstrated early successful outcomes compared to conventional component therapy. The objective of this study was to demonstrate WB transfusion in the non-trauma patient. Consecutive adult patients receiving WB transfusion at a single academic institution were reviewed from February 2018 to January 2020. Outcomes measured were mortality and transfusion-related reactions. A total of 237 patients who received WB were identified with 55 (23.2%) non-trauma patients. Eight patients (14.5%) received pre-hospital WB. The most common etiology of non-traumatic hemorrhage was gastrointestinal bleeding (43.6%, n = 24/55). Approximately half of the non-trauma patients (n = 28/55) received component therapy. Transfusion-related events occurred in 3 patients. This study demonstrated that non-trauma patients could receive WB transfusions safely with infrequent transfusion-related events. Future studies should focus on determining if outcomes are improved in non-trauma patients who receive WB transfusions and defining specific transfusion criteria for this population.

Factors affecting incorrect interpretation of abdominal computed tomography in non-traumatic patients by novice emergency physicians.

ObjectiveAccurate interpretation of computed tomography (CT) scans is critical for patient care in the emergency department. We aimed to identify factors associated with an incorrect interpretation of abdominal CT by novice emergency residents and to analyze the characteristics of incorrectly interpreted scans.MethodsThis retrospective analysis of a prospective observational cohort was conducted at three urban emergency departments. Discrepancies between the interpretations by postgraduate year-1 (PGY-1) emergency residents and the final radiologists’ reports were assessed by independent adjudicators. Potential factors associated with incorrect interpretation included patient age, sex, time of interpretation, and organ category. Adjusted odds ratios (aORs) for incorrect interpretation were calculated using multivariable logistic regression analysis.ResultsAmong 1,628 eligible cases, 270 (16.6%) were incorrect. The urinary system was the most correctly interpreted organ system (95.8%, 365/381), while the biliary tract was the most incorrectly interpreted (28.4%, 48/169). Normal CT images showed high false-positive rates of incorrect interpretation (28.2%, 96/340). Organ category was found to be a major determinant of incorrect interpretation. Using the urinary system as a reference, the aOR for incorrect interpretation of biliary tract disease was 9.20 (95% confidence interval, 5.0–16.90) and the aOR for incorrectly interpreting normal CT images was 8.47 (95% confidence interval, 4.85–14.78).ConclusionBiliary tract disease is a major factor associated with incorrect preliminary interpretations of abdominal CT scans by PGY-1 emergency residents. PGY-1 residents also showed high false-positive interpretation rates for normal CT images. Emergency residents’ training should focus on these two areas to improve abdominal CT interpretation accuracy.