Presence Of Altered Mental Status Research Articles

Clinical Characteristics and Risk Factors for Severe Japanese Spotted Fever: A Retrospective Multicenter Study in Nagasaki Prefecture, Western Japan.

Japanese spotted fever (JSF) is a tick-borne rickettsial disease prevalent in western Japan, with an increasing incidence and geographical distribution. This retrospective study aimed to describe the clinical features of JSF and identify factors associated with its severe form. We included adult patients with laboratory confirmed JSF in Nagasaki prefecture from 2010 to 2021. Severe JSF was defined by the presence of altered mental status, low blood pressure, or low oxygen saturation. In total, 65 JSF cases were diagnosed. Common symptoms were fever (87%), rash (48%), and fatigue (48%) with eschars detected in 50 (79.4%) of patients. Thirty-eight (60.3%) patients were initially diagnosed with non-JSF conditions. Twenty-one (33.3%) cases were categorized as severe JSF, including one death. Pre-hospital factors associated with severe JSF included age ≥75 (adjusted odds ratio [aOR] 37.53, 95% confidence interval [CI] 3.03-465.38), male sex (aOR 26.5, 95% CI 4.23-166.00), and a treatment delay ≥4 days from onset (aOR 5.96, 95% CI 1.13-31.60). This study highlights diagnostic challenges of JSF due to its non-organ-specific clinical presentation. Delayed initial treatment, advanced age, and male sex significantly increase the risk of severity. It is crucial to further raise awareness of JSF among clinicians and residents in endemic areas.

Psychometric properties of the Montreal Cognitive Assessment (MoCA) in inpatient liver transplant candidates

Hepatic encephalopathy (HE) is a consequence of liver disease and often diagnosed via psychometric testing. With inpatients, the Montreal Cognitive Assessment (MoCA) may be used as part of cognitive screening for transplant candidacy. However, the MoCA was developed to detect mild cognitive impairment in aging populations and its psychometric properties in inpatients with liver disease have not been determined. Retrospective chart review identified inpatient liver transplant candidates who were administered a MoCA as part of their neuropsychological screening and had either no cognitive dysfunction or a diagnosis of HE made by a neuropsychologist (n = 57, mean age = 48.8 ± 12.6 years). Psychometric analyses were conducted and regression analysis was performed to determine the predictive value of different variables on total MoCA scores. Internal consistency of MoCA domain scores was good (α = 0.80). Significant inverse relationships were found with Trail Making Test, Parts A and B (r’s = −0.43 and −0.71, respectively). A cutoff score of 24 or below had the best sensitivity (0.72) and specificity (0.77) for identifying those with a diagnosis of HE. Increasing age and the presence of altered mental status were the strongest predictors of lower MoCA scores (both p’s < 0.05, ηp 2 = 0.10–0.14). The MoCA is appropriate to use with inpatient liver transplant candidates, with a cutoff of 24 or below to detect abnormal cognition. In addition to the clinical interview and other neuropsychological tests (including, but not limited to, the Trail Making Test, Parts A and B), low MoCA scores can help determine the presence of HE.

61. Using Machine Learning for Prediction of Poor Clinical Outcomes in Adult Patients Hospitalized with COVID-19

BackgroundAs the ongoing COVID-19 pandemic develops, there is a need for prediction rules to guide clinical decisions. Previous reports have identified risk factors using statistical inference model. The primary goal of these models is to characterize the relationship between variables and outcomes, not to make predictions. In contrast, the primary purpose of machine learning is obtaining a model that can make repeatable predictions. The objective of this study is to develop decision rules tailored to our patient population to predict ICU admissions and death in patients with COVID-19.MethodsWe used a de-identified dataset of hospitalized adults with COVID-19 admitted to our community hospital between March 2020 and June 2020. We used a Random Forest algorithm to build the prediction models for ICU admissions and death. Random Forest is one of the most powerful machine learning algorithms; it leverages the power of multiple decision trees, randomly created, for making decisions.Results313 patients were included; 237 patients were used to train each model, 26 were used for testing, and 50 for validation. A total of 16 variables, selected according to their availability in the Emergency Department, were fit into the models. For the survival model, the combination of age >57 years, the presence of altered mental status, procalcitonin ≥3.0 ng/mL, a respiratory rate >22, and a blood urea nitrogen >32 mg/dL resulted in a decision rule with an accuracy of 98.7% in the training model, 73.1% in the testing model, and 70% in the validation model (Table 1, Figure 1). For the ICU admission model, the combination of age < 82 years, a systolic blood pressure of ≤94 mm Hg, oxygen saturation of ≤93%, a lactate dehydrogenase >591 IU/L, and a lactic acid >1.5 mmol/L resulted in a decision rule with an accuracy of 99.6% in the training model, 80.8% in the testing model, and 82% in the validation model (Table 2, Figure 2).Table 1. Measures of Performance in Predicting Inpatient Mortality ConclusionWe created decision rules using machine learning to predict ICU admission or death in patients with COVID-19. Although there are variables previously described with statistical inference, these decision rules are customized to our patient population; furthermore, we can continue to train the models fitting more data with new patients to create even more accurate prediction rules.Figure 1. Receiver Operating Characteristic (ROC) Curve for Inpatient Mortality Table 2. Measures of Performance in Predicting Intensive Care Unit Admission Figure 2. Receiver Operating Characteristic (ROC) Curve for Intensive Care Unit Admission Disclosures All Authors: No reported disclosures

59: qSOFA: Modifications for identifying sepsis in obstetrical patients

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Recognizing the prognostic shortcomings of SIRS-based definitions, a new system termed Sequential Organ Failure Assessment (SOFA) was developed. Quick SOFA (qSOFA) was created to identify patients at risk for poor outcomes outside of the intensive care unit setting. While there is evidence that SOFA and qSOFA are superior to SIRS in non-pregnant patients, they have not been validated in the pregnant population. A retrospective cohort study was done examining pregnant patients admitted to a single institution with severe infections. The primary outcome was defined as a composite of any of the following adverse outcomes: ICU admission for > 48 hours, need for invasive monitoring (central line or arterial line), intubation, use of intravenous vasopressors or inotropes, and maternal death. Vital signs were collected during the time of triage. Receiver Operating Characteristic (ROC) curves were constructed based on all patients in the study population. The study patients were divided into two groups: those who did or did not develop the primary outcome of interest. Then various modifications of qSOFA were evaluated (with ROC curves) to determine if any could accurately predict which patients would develop the primary outcome. A total of 104 subjects were included in the analysis, with 32 subjects having the primary outcome of interest. The actual q-SOFA (RR > 22, SBP < 100 or altered mental status (AMS)) performs very poorly in pregnancy. ROC analysis found that values in pregnancy which predicted adverse outcomes were RR ≥35 or SBP< 85 or presence of AMS. The area under this ROC curve was 0.781, (p< 0.001, sensitivity 81.2%, specificity 75%). The current qSOFA criteria is a poor predictor of adverse outcomes in pregnant patients with sepsis. Adverse outcomes in pregnant patients were better predicted using RR ≥35, SBP< 85 or AMS. Using these values, modified criteria "qSOFA-P" could be used to better predict adverse outcomes in pregnant patients with sepsis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Traumatic brain injury among two-wheeled motor vehicle riders in Utsunomiya, Japan: a comparison between mopeds and motorcycles.

Two-wheeled motor vehicles are dichotomized into mopeds and motorcycles (MCs) based on their engine capacity. While efforts have been made, mostly by European researchers, to evaluate the possible difference in the frequency/severity of riders' traumatic brain injury (TBI) between the two categories, the results have been inconsistent. To evaluate whether such differences exist in Japan, a single-center, retrospective observational study was conducted on two-wheeled motor vehicle riders wearing a helmet during high-energy road traffic accident (RTA). Between January 2011 and December 2017, 127 moped and 128 MC helmeted riders involved in RTAs had been treated in our institution. Moped riders were significantly older than MC riders (50.7 ± 25.0years vs. 35.1 ± 18.6years, p = 0.04). The frequency of TBI was significantly higher in moped riders than in MC riders (21.3% vs. 10.9%; p = 0.03). However, the frequency of other bodily injuries did not differ significantly. Among the riders with TBI, neither injury severity nor outcomes differed significantly. Multivariate regression analysis showed that the presence of altered mental status was predictive of TBI (OR 23.398; 95% CI 9.187-59.586; p < 0.001). Moped riders trended to have a higher likelihood of sustaining TBI (OR 2.122; 95% CI 0.870-5.178; p = 0.098). Mopeds are frequently utilized by elderly in Japan, which may have been causally associated with the higher frequency of TBI in moped riders, while other causes, including the difference in helmet type, may also be involved. This study is limited by its small sample size and retrospective design, and multi-center prospective studies are warranted.

Nonspecific Symptoms Lack Diagnostic Accuracy for Infection in Older Patients in the Emergency Department

To determine if nonspecific symptoms and fever affect the posttest probability of acute bacterial infection in older patients in the emergency department (ED). Preplanned, secondary analysis of a prospective observational study. Tertiary care, academic ED. A total of 424 patients in the ED, 65 years or older, including all chief complaints. We identified presence of altered mental status, malaise/lethargy, and fever, as reported by the patient, as documented in the chart, or both. Bacterial infection was adjudicated by agreement among two or more of three expert reviewers. Odds ratios were calculated using univariable logistic regression. Positive and negative likelihood ratios (PLR and NLR, respectively) were used to determine each symptom's effect on posttest probability of infection. Of 424 subjects, 77 (18%) had bacterial infection. Accounting for different reporting methods, presence of altered mental status (PLR range, 1.40-2.53) or malaise/lethargy (PLR range, 1.25-1.34) only slightly increased posttest probability of infection. Their absence did not assist with ruling out infection (NLR, greater than 0.50 for both). Fever of 38°C or higher either before or during the ED visit had moderate to large increases in probability of infection (PLR, 5.15-18.10), with initial fever in the ED perfectly predictive, but absence of fever did not rule out infection (NLR, 0.79-0.92). Results were similar when analyzing lower respiratory, gastrointestinal, and urinary tract infections (UTIs) individually. Of older adults diagnosed as having UTIs, 47% did not complain of UTI symptoms. The presence of either altered mental status or malaise/lethargy does not substantially increase the probability of bacterial infection in older adults in the ED and should not be used alone to indicate infection in this population. Fever of 38°C or higher is associated with increased probability of infection. J Am Geriatr Soc 67:484-492, 2019.

Incidence of Adverse Events During Peripheral Administration of Sodium Chloride 3.

Traditionally, sodium chloride 3% has been administered via a central venous line (CVL) because of the perceived risk of infiltration and tissue injury due to its high osmolarity. In clinical practice, sodium chloride 3% is commonly administered through peripheral venous catheters (PVCs) given the necessity of timely administration. However, there is no published data on the safety of administering sodium chloride 3% through PVCs in the adult population. The objective of this study was to evaluate the safety of peripheral venous administration of sodium chloride 3%. A retrospective review was conducted in patients who received sodium chloride 3% in the intensive care unit (ICU). Patients were excluded if they had a CVL for the entire duration of the infusion or younger than 18 years at the time of administration. Baseline patient and infusion characteristics were collected. Infusion-related adverse events (IRAEs) were recorded, graded, and interventions required were noted. A total of 66 patients were included in the analysis. The most common indication was hyponatremia and majority of the patients were managed in the neurosurgical ICU. The most common risk factor for IRAEs was the presence of altered mental status. Four patients experienced an IRAE at an event rate of 6.1%. Patients who experienced an IRAE ranged from 38 to 82 years old. The IRAEs were grade 1 in severity, managed conservatively with removal of the PVC, and 2 of the 4 patients had their infusions restarted peripherally. The time to initial IRAE ranged from 2 to 94 hours. For the entire cohort, hospital and ICU length of stay were 8 and 4 days, respectively. The rate of IRAEs related to the infusion of sodium chloride 3% through PVCs appears to be similar to those reported with other hyperosmotic agents and could be considered for patients who need time-sensitive therapy.

Predictors for moderate to severe paediatric head injury derived from a surveillance registry in the emergency department

Introduction and aimHead injuries are a common complaint among children presenting to the emergency department (ED). This study is part of an ongoing prospective surveillance of head injured children presenting to a paediatric ED. We aim to derive predictors for moderate to severe head injury in our population. Materials and methodsWe performed an unmatched case-control study. Cases were defined as those who presented to the ED with moderate to severe head injury, during the period from 2006 to 2014. Controls were obtained from the prospective surveillance head injury database and were children who presented to the ED with head injury but who remained well on follow up. We compared variables from demographics, mechanism of injury, history, and physical examination. ResultsThere were 39 cases and 1173 controls. In the prospective database, our event rate was 0.5% and our computed tomography (CT) rate was 1%. Among those with moderate to severe head injury, they were more likely to be involved in road traffic accidents, have a history of difficult arousal, confusion or disorientation and a history of seizure. On physical examination, cases were more likely to have the presence of altered mental status, base of skull fracture, scalp hematoma and anisocoria. On multivariable analysis, the following 4 predictors remained statistically significant: Involvement in road traffic accident (p<0.001), difficult arousal (p<0.001), vomiting (p=0.003) and signs of base of skull fracture (p<0.001). Using these 4 variables, the Area under Curve was 0.97 {Sensitivity 92.3% (79.1–98.4%), Specificity 93.0% (91.4–94.4%), positive predictive value 30.5% (22–40%), negative predictive value 99.7% (99.2–99.9%)}. ConclusionInvolvement in road traffic accident, difficult arousal, base of skull fracture and vomiting are independent predictors for moderate to severe head injury in our paediatric population.

Central nervous system involvement of hypereosinophilic syndrome: A report of 10 cases and a literature review

BackgroundThe central nervous system (CNS) may be affected in those cases of peripheral eosinophila without a secondary cause (hypereosinophilic syndrome, HES). The pathomechanism of CNS involvement in HES remained uncertain. MethodsWe included those with CNS symptoms and peripheral eosinophilia (>1500/μl) at the time of presentation. Those with identifiable causes of eosinophilia were excluded. In addition to data analysis of our cases, we reviewed the literature using the Medline database. ResultsTen patients were recruited. Half of them presented with altered mental status. None of the patients had significant risk factors such as endomyocardial disease (EMD). Their brain magnetic resonance imaging (MRI) showed multiple ischemic lesions in the border zone (BZ) and other cortical areas. In addition to our 10 cases we included 67 cases from a literature review. The total 77 cases were systemically analyzed. We found that the most common type of CNS involvement was cerebrovascular disease (CVD, 63.6%), multifocal lesions in BZ were the most common feature on MRI (45.5%), many patients presented with altered mental status (40.3%), and direct eosinophil infiltration into brain parenchyma was rare in pathologic studies and not found in the patients with CVD. Furthermore, although EMD was one of the major cardiac abnormalities (26.0%), cardiac workup more frequently showed non-EMD or normal findings. Cardiac abnormalities, altered mental status, and higher eosinophil counts were more common in those with poor outcomes, whereas an isolated CNS manifestation was more frequent in those with favorable outcomes. Finally, the presence of altered mental status was the most significant predictor of poor clinical outcomes, whereas isolated CNS involvement and corticosteroid treatment were significant predictors for favorable outcomes. ConclusionsMultiple lesions on MRI were suggestive of an embolic mechanism, but diagnostic workup failed to find significant risk factors such as EMD in the most cases. Impaired anticoagulation by eosinophilic cationic proteins could be an alternative mechanism. Direct invasion of eosinophils into the CNS was rare and those cases with isolated CNS manifestations showed a better prognosis. The preferential indirect involvement of CNS by eosinophils (“CNS-tropism”) may underlie the neurological manifestations of HES. Early administration of corticosteroid after ruling out secondary causes can be beneficial in HES with CNS manifestation.

The relationship between a chief complaint of "altered mental status" and delirium in older emergency department patients.

Altered mental status is a common chief complaint among older emergency department (ED) patients. Patients with this chief complaint are likely delirious, but to the authors' knowledge, this relationship has not been well characterized. Additionally, health care providers frequently ascribe "altered mental status" to other causes, such as dementia, psychosis, or depression. The objective was to determine the relationship between altered mental status as a chief complaint and delirium. This was a secondary analysis of a cross-sectional study designed to validate three brief delirium assessments, conducted from July 2009 to March 2012. English-speaking patients who were 65 years or older and in the ED for <12 hours were included. Patients who were comatose or nonverbal or unable to follow simple commands prior to the acute illness were excluded. Chief complaints were obtained from the ED nurse triage assessment. The reference standard for delirium was a comprehensive psychiatrist assessment using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivity, specificity, positive likelihood ratio (LR), and negative LR with their 95% confidence intervals (CIs) were calculated using the psychiatrist's assessment as the reference standard. A total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38). The absence of a chief complaint of altered mental status should not reassure the clinician that delirium is absent. This syndrome will be missed unless it is actively looked for using a validated delirium assessment. However, patients with this chief complaint are highly likely to be delirious, and no additional delirium assessment is necessary.

Point-of-Care Focused Cardiac Ultrasound for Prediction of Pulmonary Embolism Adverse Outcomes

BackgroundIn patients with pulmonary embolism (PE), right ventricular strain (RVS) on transthoracic echocardiography by Cardiology has been shown to be an independent predictor of 30-day adverse outcomes. However, it is not known how emergency practitioner-performed point-of-care focused cardiac ultrasound (FOCUS) with assessment for RVS compares with other prognostic methods in the Emergency Department (ED). ObjectivesTo determine whether RVS on FOCUS is a significant predictor of in-hospital adverse outcomes when compared to other risk factors and scoring systems. MethodsRetrospective chart review of patients who were diagnosed with PE and had a FOCUS examination during January 1, 2007 through January 1, 2011 in an urban, academic center with a well-developed ultrasound program. Adverse outcomes were defined as shock, respiratory failure requiring intubation, death, recurrent venous thromboembolism, transition to higher level of care, or major bleeding during hospital admission. Statistical analysis included univariate and multivariate analysis to assess for prognostic significance. ResultsOne hundred sixty-one patients were included in the final analysis. A total of 25 (16%) patients had an adverse outcome during hospitalization. On univariate analysis, only the presence of altered mental status conferred a higher positive likelihood ratio (6.4 vs. 4.0) than RVS, whereas absence of RVS had the lowest negative likelihood ratio (0.45). On multivariate analysis, RVS and cardiopulmonary disease were the only predictors of adverse outcomes that achieved statistical significance, with odds ratio of 9.2 and 3.4, respectively. ConclusionIn this retrospective chart review, a FOCUS examination for RVS performed by emergency care practitioners of varying experience level was a significant predictor of in-hospital adverse outcomes among patients diagnosed with PE in the ED. Future research should be directed at exploring ways to incorporate RVS assessment into ED prognostic models for pulmonary embolism.

Age, Nursing Home Residence, and Presentation of Urinary Tract Infection in U.S. Emergency Departments, 2001–2008

Current outpatient diagnostic algorithms for urinary tract infection (UTI) in older adults require the presence of classic signs and symptoms of UTI, such as fever and genitourinary symptoms. However, older adults with UTI may present with atypical signs and symptoms. The objective was to identify the associations of age and nursing home status with the clinical presentation of emergency department (ED) patients diagnosed with UTI. This was a retrospective, cross-sectional analysis of the 2001-2008 National Hospital Ambulatory Medical Care Survey (NHAMCS), ED component. Participants were adult ED patients diagnosed with UTI. Outcome variables were presence of fever, altered mental status, and urinary tract symptoms. Multivariable logistic regression models were constructed for each outcome. Age and nursing home status were the independent variables of interest. Age was divided into adults 18 to 64 years, older adults 65 to 84 years, and oldest adults 85 years of age and older. There were 25.4 million ED visits in which UTI was diagnosed from 2001 through 2008, including 5.0 million in older adults and 2.2 million in the oldest adults. Fever was present in 13% of adults, 21% of older adults, and 19% of the oldest adults. Altered mental status was present in 1% of adults, 7% of older adults, and 13% of the oldest adults. Urinary tract symptoms were identified in 32% of adults, 24% of older adults, and 17% of the oldest adults. In multivariable analysis, altered mental status was more common in older adults (odds ratio [OR] = 1.94) and in the oldest adults (OR = 2.49). Urinary tract symptoms were less common in older adults (OR = 0.60) and the oldest adults (OR = 0.48). Nursing home residence was associated with increased fever (OR = 1.63) and altered mental status (OR = 4.79) and with decreased urinary tract symptoms (OR = 0.35). Fever and urinary tract symptoms are absent in a large proportion of adults over 65 years of age diagnosed with UTI in the ED. Age over 65 years and nursing home residence are associated with increased presence of altered mental status and with lack of urinary tract symptoms. Nursing home residence is also associated with increased presence of fever. Emergency physicians (EPs) continue to diagnose UTI in patients without classic symptoms. Diagnostic criteria for UTI among adults 65 years and over specifically designed for use in the acute care setting should be developed and validated to prevent both inappropriate overdiagnosis and underdiagnosis of UTI.

338 EMS Sepsis Patients Are Different From Walk-in Sepsis Patients

Study Objectives: Sepsis is a leading cause of morbidity and mortality worldwide. This study is a retrospective review of quality improvement data gathered from a large teaching hospital since November 2009. The aim of this study was to compare outcomes between patients presenting by emergency medical services compared to those presenting directly to the emergency department (ED).Methods: We prospectively identified and reviewed all cases of severe sepsis admitted to the medical intensive care unit from the ED in the 2-year period between 11/1/09 and 10/1/11. Emergency medical services variables extracted were vital signs, blood glucose, presence of altered mental status and transport times. ED variables were initial ED vitals, blood glucose, presence of altered mental status and serum lactate levels. Our primary outcomes were inhospital mortality and length of hospital stay. Groups were dichotomized into those arriving to the ED via emergency medical services and those arriving independent of emergency medical services (controls).Results: Of 359 patients who met study inclusion criteria, 283 (79%) presented by emergency medical services. Two-thirds of the overall group (62%) was male; the average age was57±15 years. Patients presenting via emergency medical services were older than controls (58±14 years versus 52±17, diff= 6, 95%CI=3,10). Emergency medical services transports had lower initial lactate levels (5±4vs 6±4, diff=1,95%CI=0.1, 1.8) and were less likely to present with critically high, shock lactate levels greater than 4 (50% versus 66%, diff=16, 95%CI=0,32). Despite this difference in lactate levels, more emergency medical services patients presented with altered mental status (57% VS 30%, diff=27, 95%CI=9,42) and respiratory difficulty (66% with tachypnea VS 54%, diff=12, 95%CI=3,29). There were no differences between the groups on initial ED vital signs or blood glucose levels. There were no differences in the outcomes of length of hospital stay (10±15 versus 11±17) or mortality (32% versus 30%).Conclusion: Patients with severe sepsis transported by emergency medical services are older and have more overt signs of severity but lower lactate levels than those presenting independent of emergency medical services. Mode of ED arrival was not associated with initial vital signs or short-term mortality. Study Objectives: Sepsis is a leading cause of morbidity and mortality worldwide. This study is a retrospective review of quality improvement data gathered from a large teaching hospital since November 2009. The aim of this study was to compare outcomes between patients presenting by emergency medical services compared to those presenting directly to the emergency department (ED). Methods: We prospectively identified and reviewed all cases of severe sepsis admitted to the medical intensive care unit from the ED in the 2-year period between 11/1/09 and 10/1/11. Emergency medical services variables extracted were vital signs, blood glucose, presence of altered mental status and transport times. ED variables were initial ED vitals, blood glucose, presence of altered mental status and serum lactate levels. Our primary outcomes were inhospital mortality and length of hospital stay. Groups were dichotomized into those arriving to the ED via emergency medical services and those arriving independent of emergency medical services (controls). Results: Of 359 patients who met study inclusion criteria, 283 (79%) presented by emergency medical services. Two-thirds of the overall group (62%) was male; the average age was57±15 years. Patients presenting via emergency medical services were older than controls (58±14 years versus 52±17, diff= 6, 95%CI=3,10). Emergency medical services transports had lower initial lactate levels (5±4vs 6±4, diff=1,95%CI=0.1, 1.8) and were less likely to present with critically high, shock lactate levels greater than 4 (50% versus 66%, diff=16, 95%CI=0,32). Despite this difference in lactate levels, more emergency medical services patients presented with altered mental status (57% VS 30%, diff=27, 95%CI=9,42) and respiratory difficulty (66% with tachypnea VS 54%, diff=12, 95%CI=3,29). There were no differences between the groups on initial ED vital signs or blood glucose levels. There were no differences in the outcomes of length of hospital stay (10±15 versus 11±17) or mortality (32% versus 30%). Conclusion: Patients with severe sepsis transported by emergency medical services are older and have more overt signs of severity but lower lactate levels than those presenting independent of emergency medical services. Mode of ED arrival was not associated with initial vital signs or short-term mortality.

Emergency Department Pneumonia Patients Who do not Meet the Six-Hour Criteria for Antibiotic Administration: Do They Have a Different Clinical Presentation?

BackgroundThe Joint Commission (JC) has set a quality of care standard for emergency department (ED) patients diagnosed with community acquired pneumonia (CAP) that states that they are to receive antibiotics within six hours of presentation to the ED. Hospitals have been able to demonstrate that the majority of patients meet these criteria, yet there are still many who do not. Previously published studies have reported that there are several issues that contribute to prolonged times to antibiotic administration including ED crowding and atypical clinical presentations. This study was undertaken to identify factors existing early in the patient encounter that may be associated with failure to meet the Joint Commission’s six-hour standard for antibiotic administration.MethodsThis was an IRB-approved, retrospective observational study covering 36 months in an academic emergency department. All adults with an admission diagnosis of CAP were eligible but were excluded if their discharge diagnosis was not CAP, if hospitalized within the previous 14 days, or if HIV positive. Univariate analysis and multiple logistic regression with stepwise variable selection were performed comparing patients who met and did not meet JC standards. The analysis included demographics (age, sex), chief complaint at triage and to doctor (fever, dyspnea, cough, chest pain, weakness/fatigue, abdominal pain), presence of altered mental status, triage vital signs, co-morbidities, day of week and time of day of presentation.ResultsA total of 736 cases were eligible; 199 cases met exclusion criteria; 43 charts were unavailable; 494 were included in the study group (363 with complete antibiotic time records; 131 were incomplete). From the univariate analysis, respiratory rate (RR) and oxygen saturation were the only factors that met Bonferroni criteria for statistical significance when comparing those who met and did not meet the JC six-hour criteria (RR 25 ± 9 vs 22 ± 6 breaths/minute, respectively, P = 0.002; oxygen saturation 87 ± 10% vs 92 ± 5%, respectively, P < 0.001). Multiple logistic regression identified triage pulse rate, oxygen saturation, presence of altered mental status, hour of day, and day of week as variables associated with time to antibiotic administration. Chances for meeting the standard were increased by 10% for each 5-beat increase in pulse rate or 1% decrease in oxygen saturation. If the person exhibited altered mental status, they were > 3.5 times more likely to meet the 6-hour criteria. If they presented to ED between 3 PM and 10 PM chances of meeting criteria were reduced by about 65%. If they presented on a Thursday, chances improved 2.8 times.ConclusionsCompared to patients who did meet Joint Commission criteria, those who did not receive antibiotics within 6 hours were likely to have triage pulse rates and O2 saturation levels closer to normal, thus contributing to diagnostic uncertainty. They were also likely to present to the ED at the most crowded time of day. Likelihood to meet JC criteria was improved if O2 saturation was below normal, pulse rate was elevated, if they exhibited mental confusion, or if they presented to the ED very early or very late in the day, or on a lower census day.

Evaluation of the Standardized Assessment of Concussion in a Pediatric Emergency Department

The Standardized Assessment of Concussion (SAC) is a validated tool for identifying the effects of mild traumatic brain injury (mTBI). Previous research focused on sport-related sideline evaluation of adolescents and adults. Our goal was to evaluate performance of the SAC among subjects with and without head injury in a pediatric emergency department (ED). This was an observational study of children 6 to 18 years of age who presented to an ED with blunt head injury (case-patients) or minor extremity injury (controls). SAC and graded-symptom-checklist scores were compared. American Academy of Neurology concussion grades, presence of loss of consciousness and posttraumatic amnesia were also compared with SAC and graded-symptom-checklist scores among case-patients. Three hundred forty-eight children were enrolled. SAC scores trended lower (greater cognitive deficits) for case-patients compared with controls but did not reach significance. Graded-symptom-checklist scores were significantly higher among case-patients. Presence of altered mental status magnified this effect. There was no correlation between SAC scores and other indicators of mTBI. There was a positive correlation between graded-symptom-checklist scores and posttraumatic amnesia and American Academy of Neurology concussion grade. The graded symptom checklist reliably identified mTBI symptoms for all children aged 6 years and older. SAC scores tended to be lower for case-patients compared with controls but did not reach significance. Patients with altered mental status at the time of injury manifest an increased number and severity of symptoms. Additional research into strategies to identify cognitive deficits related to mTBI and classify mTBI severity in children is needed.

Heat stroke in a subtropical country

In Taiwan, a subtropical country without any history of heat waves, heat stroke has been considered a rare disease. However, after seeing several cases of the classic type of heat stroke at the end of the summer of 1998 (an unusual event) we began to review and collect cases of suspected heat stroke (hyperthermia (>40.6°C) in the presence of altered mental status and anhidrosis) and tried to explore the possible cause of this unusual phenomenon. Through a emergency department (ED) chart review, case retraction from International Classification of Diseases (ICD) code, and ED conferences, six patients were found for the period from June to August (the hottest months in Taiwan) 1998. We found that the most common comorbid conditions were hypertension (4/6) and preexisting mental problems (3/6). All patients lived in the inner part of an urban area, were middle class, and were not socially isolated. Most of our patients felt unhealthy being exposed to the cold and avoided staying in air-conditioned rooms. Laboratory abnormalities and clinical presentations, except for a high fever and conscious change, seemed to be nonspecific. All cases occurred during two periods of sustained hotter-than-average weather and, to our surprise, we found that three episodes occurred around the day of the highest weather temperature (38.1°C). However, the higher temperatures (around 30° to 31°C and 32° to 33°C) did not reach the criteria of a heat wave. Compared with the other study, our patients seemed to have initial worse outcomes. Because of special environment and social factors, classic heat stroke may occur occasionally in subtropic regions, without previous history of heat waves and where heat stroke rarely occurs, during periods of the persistently high temperatures. Prevention of heat stroke in an area with a low incidence includes early health organizations' issue of advisories or warnings through the media and reminding or teaching emergency physicians about heat stroke during sustained hot weather, especially when record temperatures are set. (Am J Emerg Med 2000;18:474-477.