Trauma Center Emergency Department Research Articles

Interaction of obesity and proteins associated with the NLRP3 inflammasome following mild traumatic brain injury

The NOD-like receptor pyrin domain-containing protein 3 (NLRP3) inflammasome has been associated with worse outcomes from severe traumatic brain injury (TBI). The NLRP3 inflammasome is also strongly associated with other pro-inflammatory conditions, such as obesity. Little is known about the potential effect of mild TBI (mTBI) on the NLRP3 inflammasome and the extent to which modifying factors, such as obesity, may augment the inflammatory response to mTBI. The purpose of this study was to evaluate the association of NLRP3 inflammasome proteins with obese body mass index (BMI ≥ 30) within 24 h of mTBI after presenting to a level 1 trauma center emergency department. This is a secondary analysis of prospectively enrolled patients with mTBI who presented to the emergency department of one U.S. Level 1 trauma center from 2013 to 2018 (n = 243). A series of regression models were built to evaluate the association of NLRP3 proteins obtained from blood plasma within 24 h of injury and BMI as well as the potential interaction effect of higher BMI with NLRP3 proteins (n = 243). A logistic regression model revealed a significant association between IL-18 (p < 0.001) in mTBI patients with obese BMI compared to mTBI patients with non-obese BMI (< 30). Moderation analyses revealed statistically significant interaction effects between apoptotic speck-like protein (ASC), caspase-1, IL-18, IL-1β and obese BMI which worsened symptom burden, quality of life, and physical function at 2 weeks and 6 months post-injury. Higher acute concentrations of IL-1β in the overall cohort predicted higher symptoms at 6-months and worse physical function at 2-weeks and 6-months. Higher acute concentrations of IL-18 in the overall cohort predicted worse physical function at 6-months. In this single center mTBI cohort, obese BMI interacted with higher acute concentrations of NLRP3 inflammasome proteins and worsened short- and long-term clinical outcomes.

Etiology and Characteristics of Patients Presenting with Eyelid Lacerations at a Level 1 Trauma Center.

To investigate the etiology and demographic associations of patients presenting with eyelid lacerations to a US level 1 trauma center emergency department (ED). A retrospective chart review of all patients with eyelid lacerations presenting to the ED at a single level 1 trauma center was performed. Eyelid lacerations were categorized as simple eyelid lacerations, eyelid lacerations with eyelid margin involvement, and eyelid lacerations with nasolacrimal system involvement. Data on demographics and clinical characteristics were analyzed. A total of 303 eyelid laceration cases were identified, 56% were simple eyelid lacerations, followed by 24% with nasolacrimal involvement and 20% involving the eyelid margin. Sixty percent of animal bites/scratches resulted in a nasolacrimal system involving laceration, most commonly affecting children. Falls were the most common etiology in children and patients over the age of 60. Black patients, patients presenting with concomitant ophthalmic injuries, and those with Medicaid insurance were more likely to have an assault etiology (p < 0.05 for all). Falls were the most common etiology for eyelid lacerations in children and the elderly, while assault was the most common in adults. Identifying the most common etiology by demographic factors can help raise awareness regarding targeted prevention strategies for high-risk populations.

Predictive Factors for First-Pass Intubation Failure in Trauma Patients.

The primary objective of this study was to elucidate risk factors for multiple intubation attempts (MIA) in trauma patients requiring emergent tracheal intubation (ETI). Risk factors for mortality, intensive care unit (ICU) admission, and prolonged ventilation were assessed as secondary outcomes. The association between multiple intubation attempts and adverse outcomes has been well described in the literature. Though previous studies have identified anatomical risk factors for difficult airways, no study to date has investigated predictors for MIA in a trauma setting. The retrospective study involved 174 adult patients who required ETI and who presented to a Level 1 Trauma Center's emergency department between January 2019 and December 2022. Comorbidities, demographic information, triage vitals, intubation characteristics, and patient outcomes were identified to ascertain predictive risk factors for MIA. Variables were assessed for statistical significance on unadjusted analysis. Significant variables were entered into multivariate logistic regression models to test for adjusted associations, with p≤.0.05 as statistically significant, and presented as adjusted odds ratios with 95% confidence intervals. Twenty-six (14.9%) of the 174 patients required multiple intubation attempts. There were no significant associations between MIA and patient gender, age, BMI, race, injury mechanism, or specific body region injuries. On univariate analysis, the MIA group had a statistically significant elevation in mean systolic blood pressure (151.71 ± 45.96 vs 133.55 ± 32.11, p = 0.019) and heart rate (106.30 ± 34.92 vs 93.35 ± 24.82, p < 0.032) compared to subjects with first-pass success. Elevation in systolic blood pressure (SBP) (151.71 ± 45.96 vs 133.55 ± 32.11, aOR 1.03 (1.01-1.06), p < 0.015) was an independent predictor of multiple intubation attempts. Elevation in SBP was a significant predictor of multiple intubation attempts. Critical appraisal of patients requiring ETI with elevated SBP may mitigate risk in trauma settings.

Use of the Buffalo Concussion Treadmill Test in community adult patients with mild traumatic brain injury.

The Buffalo Concussion Treadmill Test (BCTT) is used to establish exercise tolerance for rehabilitation and identify injury subtypes for youth athletes after mild traumatic brain injury (mTBI). Its utility in adult community members is unknown. Primary: To describe how adults with and without mTBI tolerate the BCTT. Secondary: To explore relationships between baseline factors, mTBI-related symptoms, and BCTT duration. Prospective, observational, longitudinal. Academic medical center. Thirty-seven adults treated in a level 1 trauma center emergency department with mTBI; 24 uninjured controls (UC). N/A. Participants completed two visits 3 weeks apart (1 week and 1 month after mTBI) including a 15-minute BCTT, the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and preinjury International Physical Activity Questionnaire. Analyses characterized BCTT response and associations between baseline factors, RPQ scores, and BCTT duration. Persons with mTBI discontinued earlier than UC at 1-week postinjury using standard discontinuation criteria for exercise intolerance. The percentage of mTBI participants with signs of possible mTBI-related intolerance was 55.6% at 1 week (36.1% for mTBI-related symptom exacerbation, 19.4% for exertion/fatigue before reaching 85% of one's age-predicted maximum heart rate [HR]) and 48.0% at 1 month (40.0% mTBI-related symptom exacerbation, 8.0% exertion without reaching the target HR). Thirty percent of UCs completed the BCTT at both assessments. UCs met discontinuation criteria for increased nonspecific symptoms (eg, pain/general discomfort and increased Visual Analog Scale ratings; 39-61%) and physical exertion (9-26%). Shorter duration was associated with higher body mass index (r = -0.42 - -0.45), shorter height (r = 0.22-0.29), female gender (r = -0.26 - -0.27), and greater RPQ symptoms (r = -0.28 - -0.47). The BCTT exacerbates mTBI-related symptoms in adult community members. Participant characteristics and noninjury factors influence performance. The findings imply the BCTT could be useful in clinical assessments of adults with mTBI. Interpretation should account for the unique characteristics of nonathletes.

Computer Simulation to Assess Emergency Department Length of Stay in Pediatric Traumatic Brain Injury.

Our study aimed to identify how emergency department (ED) arrival rate, process of care, and physical layout can impact ED length of stay (LOS) in pediatric traumatic brain injury care. Process flows and value stream maps were developed for 3 level I pediatric trauma centers. Computer simulation models were also used to examine "what if" scenarios based on ED arrival rates. Differences were observed in prearrival preparation time, ED physical layouts, and time spent on processes. Shorter prearrival preparation time, trauma bed location far from diagnostic or treatment areas, and ED arrival rates that exceed 20 patients/day prolonged ED LOS. This was particularly apparent in 1 center where computer simulation showed that relocation of trauma beds can reduce ED LOS regardless of the number of patients that arrive per day. Exceeding certain threshold ED arrival rates of children with traumatic brain injury can substantially increase pediatric trauma center ED LOS but modifications to ED processes and bed location may mitigate this increase.

Correlation Between Shock Index and Mortality in the Prehospital and Level 1 Rural Trauma Center Emergency Department Settings

Background: The shock index is a valid tool used to detect impending circulatory collapse in the pre-hospital setting. As validation of the shock index requires high sample sizes, the majority of retrospective studies have been performed at urban level 1 trauma centers. We hypothesized that the shock index would accurately predict mortality in a rural level 1 trauma center. Objective - Determine if the shock index continues to be a reliable predictive value in trauma patients for morbidity and mortality. Setting - This retrospective study was performed at a state-designated level 1 trauma center in Johnson City, Tennessee. Patients were excluded from the study if they were under the age of 18, not immediately transported to the trauma center or if insufficient data was available. The shock index was calculated as heart rate/systolic blood pressure. Both the prehospital and emergency department shock indexes were calculated, with the emergency department vital signs being the first upon arrival. Patients were divided into three categories: SI ≤ 0.7, 0.71-0.89, and ≥ 0.9. We assessed the relationship between SI, blood product usage, and outcome variables using Pearson correlation coefficients and logistic regression. Chi-square analysis was used to show the difference in mortality between the groups. Results - A higher shock index score after arrival to the emergency department experienced longer hospital, intensive care unit, and mechanical ventilation days, injury severity scores, packed red blood cells, plasma, platelets, and total blood product usage. Mortality was higher in the groups with an SI of ≥ 0.9 at the scene and arrival to the emergency department. Conclusion - Patients with a shock index &gt; 0.71-0.89 in both prehospital and emergency departments had higher mortality rates and need for transfusion. The shock index continues to be a reliable predictive value in trauma patients for morbidity and mortality.

The impact of curfews on emergency departments and orthopedic traumas.

The aim of our study was to investigate the impact of curfews imposed due to the COVID-19 pandemic on emergency department visits, orthopedic trauma frequencies, and types of trauma. In this single-center, retrospective cohort study, a total of 16,242 patients, including 3,020 trauma patients, were admitted to level 1 trauma center emergency department between April-June 2020 and 2021 (curfew group) and between April-June 2018 and 2019 (control group). Patients were separated according to emergency department triage categories and trauma mechanisms, and the changes in the days of curfew were analyzed. With the curfews, there was a 54% decrease in emergency room admissions. This decrease was seen especially in yellow and green area patients, whereas there was no significant decrease in red area patients with the highest urgency. When the effect of curfews on orthopedic traumas was analyzed, a 20% decrease was observed in trauma cases. In particular, there was a significant decrease in traffic accidents in and out of the vehicle, assault, and sports injuries, whereas there was no significant decrease in falls from the same level, motor accidents, and occupational accidents. The impact of curfews on the density of emergency departments and trauma patients will guide the health management policies to be followed in future curfews to be implemented for different reasons. In the light of this information, more effective resource management and better quality health service planning will be ensured.

Profiles of Cognitive Functioning at 6 Months After Traumatic Brain Injury Among Patients in Level I Trauma Centers

Cognitive dysfunction is common after traumatic brain injury (TBI), with a well-established dose-response relationship between TBI severity and likelihood or magnitude of persistent cognitive impairment. However, patterns of cognitive dysfunction in the long-term (eg, 6-month) recovery period are less well known. To characterize the prevalence of cognitive dysfunction within and across cognitive domains (processing speed, memory, and executive functioning) 6 months after injury in patients with TBI seen at level I trauma centers. This prospective longitudinal cohort study used data from Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) and included patients aged 17 years or older presenting at 18 US level I trauma center emergency departments or inpatient units within 24 hours of head injury, control individuals with orthopedic injury recruited from the same centers, and uninjured friend and family controls. Participants were enrolled between March 2, 2014, and July 27, 2018. Data were analyzed from March 5, 2020, through October 3, 2023. Traumatic brain injury (Glasgow Coma Scale score of 3-15) or orthopedic injury. Performance on standard neuropsychological tests, including premorbid cognitive ability (National Institutes of Health Toolbox Picture Vocabulary Test), verbal memory (Rey Auditory Verbal Learning Test), processing speed (Wechsler Adult Intelligence Scale [4th edition] Processing Speed Index), and executive functioning (Trail Making Test). The sample included 1057 persons with TBI (mean [SD] age, 39.3 [16.4] years; 705 [67%] male) and 327 controls without TBI (mean [SD] age, 38.4 [15.1] years; 222 [68%] male). Most persons with TBI demonstrated performance within 1.5 SDs or better of the control group (49.3% [95% CI, 39.5%-59.2%] to 67.5% [95% CI, 63.7%-71.2%] showed no evidence of impairment). Similarly, 64.4% (95% CI, 54.5%-73.4%) to 78.8% (95% CI, 75.4%-81.9%) of participants demonstrated no evidence of cognitive decline (defined as performance within 1.5 SDs of estimated premorbid ability). For individuals with evidence of either cognitive impairment or decline, diverse profiles of impairment across memory, speed, and executive functioning domains were observed (ie, the prevalence was >0 in each of the 7 combinations of impairment across these 3 cognitive domains for most TBI subgroups). In this cohort study of patients seen at level I trauma centers 6 months after TBI, many patients with TBI demonstrated no cognitive impairment. Impairment was more prevalent in persons with more severe TBI and manifested in variable ways across individuals. The findings may guide future research and treatment recommendations.

Network analysis and relationship of symptom factors to functional outcomes and quality of life following mild traumatic brain injury: a TRACK-TBI study.

Mild traumatic brain injury (mTBI) is a heterogenous injury which can be difficult to characterize and manage. Using cross-sectional network analysis (NA) to conceptualize mTBI symptoms offers an innovative solution to identify how mTBI symptoms relate to each other. The centrality hypothesis of network theory posits that certain symptoms in a network are more relevant (central) or have above average influence over the rest of the network. However, no studies have used NA to characterize the interrelationships between symptoms in a cohort of patients who presented with mTBI to a U.S. Level 1 trauma center emergency department and how subacute central symptoms relate to long-term outcomes. Patients with mTBI (Glasgow Coma Scale = 13-15) evaluated across 18 U.S. Level 1 trauma centers from 2013 to 2019 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 2 weeks (W2) post-injury (n = 1,593) and at 3 months (M3), 6 months (M6), and 12 months (M12) post-injury. Network maps were developed from RPQ subscale scores at each timepoint. RPQ scores at W2 were associated with M6 and M12 functional and quality of life outcomes. Network structure did not differ across timepoints, indicating no difference in symptoms/factors influence on the overall symptom network across time. The cognitive factor had the highest expected influence at W2 (1.761), M3 (1.245), and M6 (1.349). Fatigue had the highest expected influence at M12 (1.275). The emotional factor was the only other node with expected influence >1 at any timepoint, indicating disproportionate influence of emotional symptoms on overall symptom burden (M3 = 1.011; M6 = 1.076). Several symptom factors at 2-weeks post-injury were more strongly associated with incomplete recovery and/or poorer injury-related quality of life at 6 and 12 months post-injury than previously validated demographic and clinical covariates. The network analysis suggests that emotional, cognitive, and fatigue symptoms may be useful treatment targets in this population due to high centrality and activating potential of the overall symptom network.

Quality evaluation of the usefulness of an emergency department fall risk assessment tool

IntroductionFalls that occur within a hospital setting are difficult to predict, however, are preventable adverse events with the potential to negatively impact patient care. Falls have the potential to cause serious or fatal injuries and may increase patient morbidity. Many hospitals utilize fall “predictor tools” to categorize a patient's fall risk, however, these tools are primarily studied within in-patient units. The emergency department (ED) presents a unique environment with a distinct patient population and demographic. The Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT) has shown to be effective with predicting a patient's fall risk in the ED. This IRB-approved study aims to assess the predictive validity of the MEDFRAT by evaluating the sensitivity and specificity for predicting a patient's fall risk in an emergency department at a level 1 trauma center. MethodsA retrospective cohort analysis was conducted using an electronic medical record (EMR) for patients who met study inclusion criteria at a level 1 trauma center ED. Extracted data includes MEDFRAT components, demographic information, and data from the Moving Safely Risk Assessment (MSRA) Tool, our institution's current fall assessment tool. A receiver operating characteristic (ROC) curve was constructed to determine the best cutoff for identifying any fall risk. Sensitivity, specificity, accuracy, positive likelihood ratio (LR+) and negative LR (LR-), with 95% CIs were then calculated for the cutoff value determined from the ROC curve. To compare overall tool performance, the areas under the ROC curves (AUC) were determined and compared with a z-test. ResultsThe MEDFRAT had a significantly higher sensitivity compared to the MSRA (83.1% vs. 66.1%, p = 0.002), while the MSRA had a significantly higher specificity (84.5% vs. 69.0%, p = 0.012). For identifying any level of fall risk, ROC curve analysis showed that the cutoff providing the best trade-off between sensitivity and specificity for the MEDFRAT was a score of ≥1. Additionally, area under the curve was determined for the MEDFRAT and MSRA (0.817 vs. 0.737). ConclusionThis study confirms the validity of the MEDFRAT as an acceptable tool to predict in-hospital falls in a level 1 trauma center ED. Accurate identification of patients at a high risk of falling is critical for decreasing healthcare costs and improving health outcomes and patient safety.

The Association between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers.

To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. Most children in the US receive initial trauma care at non-pediatric centers. The National Pediatric Readiness Project (NPRP) aims to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) in 2019-21 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15y) were calculated using Pediatric TQIP models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. 66,588 children from 630 centers with a median [IQR] wPRS of 79 [66-93] were analyzed. The average observed-to-expected odds of mortality (1.02 [0.97-1.06]) for centers in the highest quartile (wPRS≥93) was lower than any of the lowest three wPRS quartiles (1.19 [1.14-1.23](Q1), 1.29 [1.24-1.33](Q2), and 1.28 [1.19-1.36](Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality (standardized beta -0.095 [-0.146--0.044]). Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.

Radiologic blind spots in hip and pelvic radiographs.

The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs. A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated. Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital. A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.

Electric Scooter Injuries in Tampa, Florida, Are Associated With High Rates of Head Injury, Hospital Admission, and Emergency Medical Service Transport and Low Rates of Helmet Use.

Background Standing electric scooters (e-scooters) were introduced in Tampa, Florida, in 2019. We reviewed 292 e-scooter injury cases at the Tampa General Hospital Emergency Department (ED) to determine what insights we could gain. We sought to identify the characteristics of such presentations, including chief complaint (CC), patient age, day of the week, time of day, length of stay, disposition, acuity, and means of arrival to the ED. We were particularly interested in studying the rates of hospital admission, Emergency Medical Service (EMS) transport, emergent acuity presentations, and head injuries. We also sought to identify the prevalence of alcohol use prior to e-scooter accidents and its effect on the above factors. Methodology This was a retrospective chart review and was exempt from the University of South Florida's Institutional Review Board approval (STUDY004031). Data from routine clinical care in the Tampa General Hospital ED, a Level-1 Trauma Center ED in Tampa, Florida, from July 19, 2019, to May 30,2022, were collected through an operational report within the business intelligence infrastructure of the hospital's electronic medical record system. Data from patients with scooter injury-related encounter codes were extracted to an electronicdata capture form and deidentified. Narratives were reviewed to exclude uncertain cases (e.g., patients with moped, kick scooter, mobility scooter injuries, etc.) and to flag for alcohol endorsement, altered mental status, helmet usage, and head injuries that were not listed as the CC. CC, means of arrival, acuity, disposition, arrival/departure day of week, and arrival/departure hour were collected. Data analysis was completed using Microsoft Excel version 16.5 (Microsoft Corp., Redmond, WA, USA) and SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, USA). Results A total of 292 of 442 collected cases remained after removing irrelevant flags. Overall, 30.8% (n = 90) of patients were between the ages of 21 and 30, and most patients presented on weekends and nights. Moreover, 40.8% (n = 119) suffered head injuries, 40.8% (n = 119) arrived via EMS, 31.5% (n = 92) were admitted to the hospital, and 18.8% (n = 55) were designated as emergent acuity. Apart from the admission rate, these rates were all higher among alcohol endorsers (39, 13.4%) than non-endorsers (253, 86.6%). Only 2.1% of patients endorsed helmet use. Conclusions We found higher rates of hospital admission and EMS transports in our ED than many previous studies in urban areas have reported. Our data suggest that alcohol use increases the risk of more serious e-scooter injuries, characterized by higher acuity, EMS transport rate, and head injuries among alcohol endorsers. These findings are highly relevant due to the rapidly growing e-scooter presence across the United States and may serve to inform hospitals and EMS systems regarding their role in injury management, as well as future policy regarding their safe use.

High Rate of HIV Among Trauma Patients Participating in Routine Emergency Department Screening.

Limited published data suggest rates of HIV may be high among trauma patients. This study compares rates of HIV screening and diagnosis among trauma and medical patients at a Level 1 trauma center emergency department (ED) with a universal HIV screening program. This is a retrospective cross-sectional study of all ED encounters from May 1, 2018, through May 1, 2021. Duplicate encounters, encounters with repeat testing within one year, and patients younger than 18 or older than 65 were excluded. Chi-squared analysis was used to compare demographics, rates of HIV testing, new and known HIV infections, and linkage to care between trauma and medical patients. After exclusion criteria were applied, 147,430 encounters from 91,468 unique patients were analyzed. Trauma comprised 7,497 (5.4%) encounters. Trauma patients were less likely to be screened for HIV than medical patients (18.1% vs 25.6%; OR 0.64; 95%CI, 0.61-0.68, p < .01). Trauma patients had higher rates of HIV (2.2% vs 1.3%; OR 1.78; 95% CI, 1.22-2.58, p < .01). Both trauma and medical patients would benefit from strategies to increase screening. Including trauma patients in routine ED HIV screening should be a priority to increase diagnosis rate and linkage to care in key populations.

Optimal Image Gain Intensity of Point-of-care Ultrasound when Screening for Ocular Abnormalities in the Emergency Department.

Point-of-care ultrasound (POCUS) plays a pivotal role in evaluating ocular complaints in the emergency department (ED). The rapid and non-invasive nature of ocular POCUS makes it a safe and informative imaging modality. Previous studies have investigated using ocular POCUS to diagnose posterior vitreous detachment (PVD), vitreous hemorrhage (VH), and retinal detachment (RD); however, there are few studies that assess image optimization techniques and how they impact the overall accuracy of ocular POCUS. We performed a retrospective review of ED patients who received ocular POCUS examinations and ophthalmology consultations as part of their evaluation for eye complaints at our urban, Level I trauma center ED from November 2017-January 2021. Of 706 exams, 383 qualified for the study. In this study we primarily investigated how stratified gain levels impact the accuracy of ocular POCUS for detection of any posterior chamber pathology and, secondarily, whether stratified gain levels impact the accuracy of detecting RD, VH, and PVD specifically. The images were found to have an overall sensitivity of 81% (76-86%), specificity of 82% (76-88%), positive predictive value (PPV) of 86% (81-91%), and negative predictive value (NPV) of 77% (70-83%). Images acquired with a gain of (25, 50] had a sensitivity of 71% (61-80%), specificity of 95% (85-99%), PPV of 96% (88-99%), and NPV of 68% (56-78%). Images acquired with a gain of (50, 75] had a sensitivity of 85% (73-93%), specificity of 85% (72-93%), PPV of 86% (75-94%), and NPV of 83% (70-92%). Images acquired with a high gain (75, 100] had a sensitivity of 91% (82-97%), specificity of 67% (53-79%), PPV of 78% (68-86%), and NPV of 86% (72-95%). In the ED setting, high (75, 100] gain on ocular POCUS scanning has a higher degree of sensitivity for detecting any posterior chamber abnormality, as compared to low (25, 50] gain levels. Thus, incorporating the use of high gain for ocular POCUS exams produces a more effective tool for ocular pathologies in acute care settings and may be particularly valuable in resource-limited settings.

Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study.

Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality. Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints. Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use. The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

Care of Bullet-related Injuries: A Cross-sectional Study of Instructions and Prescriptions Provided on Discharge from the Emergency Department.

There are more than 80,000 emergency department (ED) visits for non-fatal bullet-related injuries (BRI) per year in the United States. Approximately half of these patients are discharged home from the ED. Our objective in this study was to characterize the discharge instructions, prescriptions, and follow-up plans provided to patients discharged from the ED after BRI. This was a single-center, cross-sectional study of the first 100 consecutive patients who presented to an urban, academic, Level I trauma center ED with an acute BRI beginning on January 1, 2020. We queried the electronic health record for patient demographics, insurance status, cause of injury, hospital arrival and discharge timestamps, discharge prescriptions, and documented instructions regarding wound care, pain management, and follow-up plans. We analyzed data using descriptive statistics and chi-square tests. During the study period, 100 patients presented to the ED with an acute firearm injury. Patients were predominantly young (median age 29, interquartile range 23-38 years), male (86%), Black (85%), non-Hispanic (98%), and uninsured (70%). We found that 12% of patients did not receive any type of written wound care instruction, while 37% received discharge paperwork that included instructions to take both an NSAID and acetaminophen. Fifty-one percent of patients received an opioid prescription, with a range from 3-42 tablets (median 10 tablets). The proportion of patients receiving an opioid prescription was significantly higher among White patients (77%) than among Black patients (47%). There is variability in prescriptions and instructions provided to survivors of bullet injuries upon ED discharge at our institution. Our data indicates that standardized discharge protocols could improve quality of care and equity in the treatment of patients who have survived a BRI. Current variable quality in discharge planning is an entry point for structural racism and disparity.

Salivary Cortisol Dynamics After Mild Traumatic Brain Injury.

To assess mild traumatic brain injury (mTBI)-related alterations in baseline (resting) salivary cortisol and cortisol reactivity to cognitive and exercise stressors, which are frequently encountered during mTBI rehabilitation and recovery. Persons with mTBI were recruited from a level 1 trauma center emergency department. Uninjured controls (UCs) were recruited from the community. Participants were 37 individuals with mTBI and 24 UCs. All patients with mTBI were enrolled at 7 ± 3 days post-injury, met the American Congress of Rehabilitation Medicine definition of mTBI, and had no acute intracranial findings on clinical neuroimaging (if performed). A prospective cohort study design was used. All participants provided saliva samples 10 times during each of 2 visits spaced 3 weeks apart (1 week and 1 month post-injury for the mTBI group). Each visit included baseline saliva sampling and sampling to evaluate reactivity to a cognitive stressor (Paced Auditory Serial Addition Test) and physical stressor (Buffalo Concussion Treadmill Test [BCTT]). Natural log-transformed salivary cortisol was measured by enzyme immunoassay. Cortisol was predicted using a linear mixed-effects model by group (mTBI and UC), visit (1 week and 1 month), and saliva sample. Mean salivary cortisol was higher in the mTBI group (1.67 nmol/L [95% CI 1.42-1.72]) than in controls (1.30 nmol/L [1.12-1.47]), without an mTBI × time interaction. At 1 week, the mTBI group had greater cortisol reactivity in response to the BCTT. Higher cortisol in individuals with mTBI at 1 week and 1 month post-injury extends previous findings into the subacute recovery period. Furthermore, the mTBI group demonstrated a greater cortisol response to mild-to-moderate aerobic exercise (BCTT) at 1 week post-injury. Given the increasing role of exercise in mTBI rehabilitation, further research is warranted to replicate these findings and identify the clinical implications, if any, of enhanced hypothalamic-pituitary-adrenal axis responses to exercise in civilians with recent mTBI.

Transfer patient imaging: secondary interpretation reimbursement.

Trauma center radiologists vary widely in the degree to which they provide secondary interpretations for transferred patients' advanced imaging. A general perception of uncertainty over reimbursement for these exams often results in reluctance to provide routine overreads. The purpose of this study is to assess the difference in reimbursement rates between primary interpretations and secondary interpretations in the emergency department (ED) setting. Billing records for the three CT procedures most commonly performed in a single, major level 1 trauma center ED from January 1, 2021, to December 31, 2021, constituted the dataset. Gross charges, total receipts, and payer status were recorded for each exam, and reimbursement rates calculated. In total, 19,754 exams met the inclusion criteria. Primary interpretation was performed on 16,507 (83.6%) exams and secondary interpretation on 3247 (16.4%). For the three CPT codes examined, the average reimbursement percentage was 32.9% for primary interpretation and 43.5% for secondary interpretation. The average reimbursement percentage for commercial payers was 56.5% for primary interpretation and 65.9% for secondary interpretation. The average reimbursement percentage for Health Insurance Exchange payers was 58.5% for primary interpretation and 59.5% for secondary interpretation. The average reimbursement percentage for Medicaid was 24.7% for primary interpretation and 39.9% for secondary interpretation. The average reimbursement percentage for Medicare was 31.1% for primary interpretation and 30.2% for secondary interpretation. The average reimbursement percentage for self-paying patients was 2.3% for primary interpretation and 3.5% for secondary interpretation. Regardless of payer status, reimbursement for secondary interpretation of the three most common transfer patients' CT exams is near or greater than that of primary interpretations.

The impact of post-intubation hypotension on length of stay and mortality in adult and geriatric patients: a cohort study.

To evaluate the association between standard post-intubation hypotension (< 90mmHg) and in-hospital mortality. Secondary objectives were to evaluate the association of post-intubation hypotension and length of stay and to assess the impact of increasing post-intubation hypotension threshold to 110mmHg on hospital length of stay and 48h-mortality in patients aged ≥ 65years. Design and setting: A cohort of patients admitted in a level-1 trauma centre emergency department (ED) between November 2011 and July2016. aged ≥ 16 with available pre-intubation vital signs, intubation performed in ≤ 3 attempts with no surgical access needed. Prospective electronic data collection was used for clinical data. 48-h in-hospital mortality. hospital length of stay. Univariate and multivariate analyses. A total of 586 patients were included. The mean age was 56.3 ± 18.8years and 37% were aged ≥ 65years. Within 60min of intubation, 224 (38%) patients had at least one systolic blood pressure measure < 90mmHg and 164(28%) had at least two measures. The < 110mmHg threshold showed a total of 377 patients (64%) had at least one systolic blood pressure measure < 110mmHg and 286 (49%) had at least two measures. We found no significant difference in the risk of mortality overall and in stratified-age groups and no association with increased hospital length of stay using both post-intubation hypotension thresholds. Post-intubation hypotension was recorded in one out of three patients in the ED but we found no association between post-intubation hypotension and 48-h in-hospital mortality overall in adults or geriatric patients.