Unstable Vital Signs Research Articles

Patients Readmitted to ICUs: A Systematic Review of Risk Factors and Outcomes

To evaluate the causes, risk factors, and mortality rates associated with unexpected readmission to medical and surgical ICUs. MEDLINE citation review of primary articles focusing on ICU readmission or ICU outcomes from January 1966 to June 1999, and contact with authors of primary studies. Eight primary studies of ICU readmission and eight multi-institutional ICU outcome studies that reported ICU readmission rates were included. We abstracted data on the methodology and design of the primary studies, overall rates, causes, predictors, outcomes, and measures of quality of care associated with ICU readmission. The average ICU readmission rate of 7% (range, 4 to 14%) has remained relatively unchanged in both North America and Europe. Respiratory and cardiac conditions were the most common (30 to 70%) precipitating cause of ICU readmission. Patients readmitted to ICUs had average hospital stays at least twice as long as nonreadmitted patients. Hospital death rates were 2- to 10-times higher for readmitted patients than for those who survived an ICU admission and were never readmitted. Predictors of ICU readmission have been neither well studied nor reproducible. Unstable vital signs, especially respiratory and heart rate abnormalities, and the presence of poor pulmonary function at time of ICU discharge appear to be the most consistent predictors of ICU readmission. There were no consistent data supporting the use of readmission rates as a measure of quality of care. ICU readmission is associated with dramatically higher hospital mortality. Unstable vital signs at the time of ICU discharge are the most consistent predictor of ICU readmission. Further studies focusing on processes of ICU and hospital care are needed to determine if ICU readmission rates are a measure of quality of care.

Difficult Airway Management in a Patient with Traumatic Asphyxia

Difficult Airway Management in a Patient with Traumatic Asphyxia

Thoracic gunshot wounds in children under 17 years of age

Over the past decade there has been a significant increase in the incidence of gunshot wounds (GSW) among Americans under 19 years of age. Despite the increase, pediatric GSW have received little attention in the literature, and no study has focused on pediatric victims of thoracic GSW. In the present study, the authors performed a retrospective review of the records of 51 patients under 17 years of age who were treated for thoracic GSW at adjoining level I pediatric and adult trauma centers between July 1987 and June 1995. The primary catchment area for these institutions is a lower socioeconomic, urban tenancy. The study population was 80.4% male and 86.3% black; the mean age was 12.4 years. The mean injury severity score and trauma score were 13.6 and 13.4, respectively. Although statistically significant differences could not be demonstrated with this population size, trends were evident when the group was subdivided by age group (≤12 years and >12 years of age). The younger group was more likely to require a thoracic operation after injury (35.3% v 23.5%), to have unstable vital signs (41.2% v 26.5%), to have a higher total abbreviated injury score (AIS) for the chest (4.8 v 4.0); however, their total extrathoracic AIS was lower (2.1 v 3.1). The younger group spent more time in the hospital and in the intensive care unit (7.6 v 4.6 days and 2.0 v 0.9 days, respectively). The younger children were more likely to have sustained injury by unintentional crossfire (35.3% v 14.7%) and were never injured by intentional assault (0% v 47.2%). Overall, 50% of the patients required surgery, including 93.8% of the patients who had unstable vital signs at the time of arrival. All six deaths (11.8%) owing to the thoracic injury occurred in patients who had mediastinal injury that required an emergency-department thoracotomy (EDT). The authors conclude that among this predominantly black male population, there are different trends with respect to treatment, circumstances, and pattern of injury between the younger and older subpopulations.

Pitfalls of nonoperative management of blunt abdominal trauma in children in Korea

During the past decade, the nonoperative management of children with blunt abdominal trauma without operation has improved dramatically by virtue of the development of medical technology. However, missed injuries or complications after nonoperative management often are associated with serious morbidity. The authors evaluated 86 patients between 1990 and 1994 who had intraabdominal solid-organ injury (excluding retroperitoneal organs) owing to blunt trauma. The liver was injured in 43 cases, the spleen in 36, and the pancreas in 14. Initially, 68 patients (79%) were managed conservatively and 18 underwent surgery because of unstable vital signs or associated injuries. Three patients had delayed surgery more than 48 hours after trauma) because of initially missed injuries (complete infarction of the spleen, duodenal injury, major pancreatic injury). Eleven patients (17%) with nonoperative management had a total of 13 complications. The most common complications were pleural effusion (6) and atelectasis (3). One patient had prolonged ileus owing to delayed absorption of an intraperitoneal hematoma, and the symptom was relieved by aspiration of the hematoma. A huge hepatic subcapsular hematoma developed in another patient and required percutaneous drainage with a pigtail catheter for 5 weeks. A pancreatic pseudocyst detected on the 16th hospital day also was drained with a pigtail catheter. A splenic abscess developed in another patient 24 days after a splenic injury, which was treated with ultrasound-guided aspiration. No patients died as a result of nonoperative management. In conclusion, even though patients with blunt abdominal trauma are stabilized and nonoperative management decided on, careful follow-up for a prolonged period is still necessary to prevent missed injuries or late complications.

Airway control in trauma patients with cervical spine fractures.

Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial. This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma. The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma. The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway--CSF--breathing spontaneously, stable vital signs; 2) Urgent airway--CSF--breathing spontaneously, unstable vital signs; and 3) Emergent airway--CSF--apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures. Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81%, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%. The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation. The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.

Primary Mesenteric Venous Thrombosis: An Unusual Cause of Abdominal Pain in a Young, Healthy Woman

A 24-year-old woman presented to the emergency department with acute abdominal pain and a physical examination consistent with acute pelvic inflammatory disease. She was treated and released only to return several hours later with worsening of her condition and unstable vital signs. Laparotomy revealed acute mesenteric venous thrombosis with patent mesenteric arteries. This is an unusual case of mesenteric thrombosis in a young, healthy woman. [Mock JN, Orsay EM: Primary mesenteric venous thrombosis: An unusual cause of abdominal pain in a young, healthy woman. Ann Emerg Med February 1994;23:352-355.]

Variables predicting the need for a pediatric critical care transport team

To determine when a pediatric critical care transport team is required to transport a patient to a referral center, this cross-sectional study evaluated 369 consecutive pediatric transports by stepwise multiple logistic regression analysis of six variables: age, vital signs, seizure activity, current endotracheal intubation, respiratory distress, and respiratory diagnosis. Models were developed for three outcome variables: 1) Major procedures were required in 8.9% of cases. The predicted probability of needing a major procedure was increased for intubated patients (probability of 12.9%), patients less than 1 year of age with unstable vital signs (12.9%), and patients meeting both these criteria (23.2%). 2) A posttransport assessment of need for a physician on the team was positive in 43% of cases. The probability of needing a physician was increased for intubated patients (probability of 68.8%), patients less than 1 year of age with unstable vital signs (58.7%), and patients meeting both these criteria (79.9%). 3) Category 1 drugs, ie, medications requiring ICU monitoring, were used in 19% of transports. The probability of this occurring was increased for intubated patients with stable vital signs (probability of 24.7%) and for intubated patients with unstable vital signs (41.4%). None of the other pretransport variables, alone or in pairs, was a significant predictor of any of the three outcome variables. The data indicate that intubation, age, and vital sign status can be used in predicting whether a transport team is needed.

Current management of liver and splenic blunt trauma in children

Thirty-nine children with blunt liver and/or splenic injury were treated in our department from 1979 to 1987; 23 had a splenic injury, 10 a hepatic injury, and the remaining 6 had both. The diagnosis was suggested by the history and physical examination and was confirmed by CT and radioisotope scanning. Every hemodynamically stable patient was initially managed non-operatively. The children who failed to respond to conservative treatment and had unstable vital signs indicating intractable hemorrhage were eventually operated upon. Every effort was made to preserve the liver and spleen during the operation. Liver repair, splenorraphy alone or in combination with splenic artery ligation, and autotransplantation of splenic tissue were widely used procedures. Sixteen patients were successfully managed nonoperatively, but the remaining 23 required surgery. Only 5 children became completely asplenic and no liver lobe resection was performed. It is suggested that conservative management of children with liver and/or splenic injury is both safe and effective. When surgical intervention is inevitable great effort should be made to preserve liver and spleen.

Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers: A prospective, randomized trial

This study prospectively compares multipolar electrocoagulation and injection therapy in high-risk patients with bleeding ulcers. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia and unstable vital signs, transfusion of ≥ 2 U of blood in 12 hours, or a decrease in hematocrit of ≥ 6% in 12 hours. Sixty patients with endoscopic evidence of an ulcer with active bleeding (n = 26) or a nonbleeding visible vessel (n = 34) were randomly assigned to receive multipolar electrocoagulation or injection with absolute ethanol. Hemostasis was achieved in 14 of 14 actively bleeding patients with multipolar electrocoagulation vs. 10 of 12 (83%) treated with injection. No significant differences were observed between electrocoagulation and injection therapy in any parameter assessed during the hospitalization: incidence of further bleeding (6% vs. 10%), units of blood transfused after treatment (1.8 ± 0.6 vs. 1.3 ± 0.4), incidence of surgery for bleeding (6% vs. 7%), length of hospital stay in days (5.8 ± 0.9 vs. 7.2 ± 2.5), cost of hospitalization ($7160 ± $1630 vs. $8520 ± $2960), or mortality rate (3% vs. 3%). Treatment induced bleeding in nonbleeding visible vessels in 35% of subjects in each group, but this was controlled with continued treatment in all patients. One delayed perforation occurred 9 days after multipolar electrocoagulation. Multipolar electrocoagulation and injection therapy are of comparable efficacy in the treatment of patients with clinical evidence of a major upper gastrointestinal bleed and endoscopic evidence of an ulcer with active bleeding or a nonbleeding visible vessel.

Pediatric risk of mortality (PRISM) score: A poor predictor in triage of patients for pediatric transport

71 Variables Predicting the Need for Major Procedures During Pediatric Critical Care Transport KA McCIoskey, W King/The Children's Hospital, Harvard Medical School, Boston, Massachusetts; The Children's Hospital of Alabama Few standards exist for determinat ion of when to use a pediatric critical care transport team to transfer an acutely ill child from a nonpediatric hospital to a tertiary care center. This cross-sectional study evaluated clinical criteria to aid in that determination. Three hundred sixty-nine pediatric transports were evaluated by mult iple logistic regression analysis on six variables: age, vital signs, recent seizure activity, current endotracheal intubation, current respiratory distress, and respiratory diagnosis. The outcome variable was the need for major procedures (chest tube intubation, intraosseous infusion, umbil ical catheter placement) during transport. Major procedures were performed during 33 of the 369 transports (8.9 %). Patients wi th current in tubat ion had 2.1 t imes the odds of requiring a major procedure as compared wi th a nonin tuba ted pat ient (P = .07, alpha = .10). Patients less than 1 year of age wi th unstable vital signs had 6.4 t imes the odds of requiring a major procedure compared wi th patients in that age group wi th stable vital signs (P = .004). In patients older than or age l, vital sign stabili ty was not a significant factor (P = .41). If intubation, age, and vital sign status were used as above to determine the use of the transport team, 113 of the 369 transports (30%) would have used the team. The true-positive rate, that is, cases in which the procedural expertise of the t eam/MD was needed, would have been 18.6%. The false-negative rate, tha t is, cases in which the t eam/MD was not used but procedural expertise was needed was 4.9%.

Central Lung Injuries

During a 7-year period (1980-1987), 161 patients underwent emergency thoracotomy for penetrating lung injuries. Of these, 25 (15%) had injuries involving central pulmonary (hilar) vascular structures. Anterolateral thoracotomies were performed in 14 patients because of unstable vital signs (ten) or cardiac arrest (four), and only two (14%) of these patients survived. In seven of these patients the incision was extended into a bilateral thoracotomy to provide better exposure for continued severe bleeding, and all seven died. Of 11 relatively stable patients having a posterolateral incision (ten) or a median sternotomy (one), only two (18%) died. Of 18 patients in whom the initial procedure was hilar clamping, ten (63%) survived. In seven patients an attempt was made to control the bleeding before hilar clamping and only one (14%) survived. In six patients, resection of a lobe (five) or a segment (one) was used to achieve hemostasis with five (83%) survivors. Eight of the 14 deaths were clearly due to blood loss, which was treated with an average of 19.5 units of blood. However, in six of the earlier deaths with much less blood loss, air emboli may have been a factor, but was unproven. Early vascular control at the hilum for central lung injuries seems to be needed not only to stop the bleeding but also to prevent systemic air emboli.

Serum alcohol levels, toxicology screens, and use of the breath alcohol analyzer

The emergency physician sees a large number of patients with problems related to the ingestion of alcohol, drugs, and toxins, and must be prepared to deal with them in an efficient and cost-effective manner. This article discusses a rationale for ordering serum alcohol levels and toxicology screens, as well as use of the breath alcohol analyzer. A serum alcohol level should be reserved for patients in whom the alcohol level is necessary to confirm a diagnosis or to guide treatment. An alcohol level is indicated when alcohol use is combined with a significant alteration in mental status, multiple drug overdose, head injury, coma, major trauma, seizures, or psychosis. The breath alcohol analyzer is useful when rapid determination of alcohol levels is desired, particularly with coma or coexisting head trauma. A low or negative level in this case rapidly alerts the physician to the presence of another condition that may require additional testing. Toxicology screening should be performed when suspected drug or toxin ingestion is combined with coma, convulsions, head injury with altered mental status, unstable vital signs, alterations in acid-base or electrolyte status, or psychosis. The screen also may be used to determine the need for a specific antidote or means of increasing excretion of a toxin, or to determine the presence of a drug that should be quantified to guide management. Open communication with the laboratory and the use of rapid screening tests markedly increase the benefit of toxicology screening.

Predictors of outcome in massive upper gastrointestinal hemorrhage.

We reviewed 100 consecutive cases of massive upper gastrointestinal hemorrhage (UGIH). The criteria for inclusion were a decrease in hematocrit greater than or equal to 6%, unstable vital signs, and greater than or equal to units of blood transfused (16 +/- 18 units, mean +/- SD). A multiple regression analysis of 96 variables was employed to determine the most accurate predictors of outcome. The overall mortality was 35%. Hospital status (whether the patient was an inpatient or outpatient when the UGIH began) showed a striking association with mortality (70% for inpatients vs. 22% for outpatients, p less than 0.001). Nonsurvivors also had a greater number of life-threatening diseases than survivors (1.4 +/- 1.1 vs. 0.3 +/- 0.5, p less than 0.001) and greater transfusion requirements (27 +/- 20 units vs. 10 +/- 13 units, p less than 0.001). Age, the presence of cirrhosis, and recent excessive alcohol intake were not important risk factors. At presentation, the most reliable predictor of a fatal outcome was the brevity of the interval between the onset of bleeding and the initiation of a medical work-up. The primary predictor when considering the entire hospitalization was the number of life-threatening diagnoses. Our data indicate that stratification for hospital status and for other potentially predictive risk factors should be incorporated in future trials of therapy for UGIH.

An unusual presentation of spontaneous pneumomediastinum

Spontaneous pneumomediastinum is an uncommon disease that often presents with subtle clinical and radiographic findings. During a two-week period, three patients presented with complaints of throat and neck pain. The first complained of difficulty swallowing and throat and chest discomfort; accurate diagnosis was delayed because of the unusual presenting symptoms. The second had severe throat pain. The third presented with unstable vital signs, throat and neck pain, and air in the pericardium and mediastinum. Review of the first case facilitated the correct diagnosis of spontaneous pneumomediastinum in the subsequent cases. All three patients were discharged free of symptoms.

Management of penetrating neck injuries.

In 44 patients neck wounds penetrating the platysma were evaluated over a 5-year period. Twenty-one patients were admitted and observed; 22 patients were explored immediately. One was dead upon arrival in the emergency room. The decision to explore was based upon initial clinical evaluation using criteria of unstable vital signs, bleeding, hematoma, subcutaneous emphysema, respiratory distress, or neurologic deficits. Of the 21 patients selected for observation, none had complications or required later surgery. There was a negative exploration rate of 23%. Had all patients been explored, the negative exploration rate would have been 60%. We conclude that selective exploration, based upon careful clinical evaluation, is both safe and reasonable in cases of penetrating neck trauma.

The role of computed tomography in the evaluation of blunt abdominal trauma in children

Computed tomography was used in the evaluation and follow-up of blunt intra-abdominal injuries in 46 children. The use of this modality resulted in a rapid and accurate diagnosis in the patients studied. Indications for CT scan examination included: a stable clinical state, symptoms and signs suggestive of intra-abdominal injury, hypotension responding to minimal fluid resuscitation, slowly declining hematocrit, hematuria, or suspicious radiographs. Patients with unstable vital signs were not considered candidates for CT scanning. The value of the protocol and CT scanning procedure itself was evident by the high yield of positive results (74% of the patients studied). Of the 12 children with urologic trauma, 2 had severe renal injuries that were not suspected by infusion i.v. pyelography and in one instance by arteriography. The magnitude and extent of perirenal hemorrhage was easily demonstrated. Thirteen patients had splenic lacerations, while 7 children had suspected hepatic injuries all accurately demonstrated by CT scans. Intra-peritoneal blood was easily detected. Two patients had pancreaticoduodenal injuries. Eleven of 12 renal injuries, 9 of 13 splenic lacerations, 5 of 7 hepatic injuries, and both pancreaticoduodenal injuries were successfully treated nonoperatively. The appropriateness of conservative management was substantiated by periodic follow-up examinations. This study demonstrated the improved sensitivity of CT scanning and ability to visualize intra- and retroperitoneal structures simultaneously when compared to more conventional methods of radiographic evaluation. The applications of CT scanning in the evaluation of the traumatized patient reduces the number of ancillary tests required for diagnosis, provides more accurate information regarding the extent and severity of the injury, and results in more appropriate decisions regarding the need for exploration versus nonoperative management. In addition, this modality offers an accurate method for long-term follow-up, allowing definitive recommendations concerning activities. Computed tomography was used in the evaluation and follow-up of blunt intra-abdominal injuries in 46 children. The use of this modality resulted in a rapid and accurate diagnosis in the patients studied. Indications for CT scan examination included: a stable clinical state, symptoms and signs suggestive of intra-abdominal injury, hypotension responding to minimal fluid resuscitation, slowly declining hematocrit, hematuria, or suspicious radiographs. Patients with unstable vital signs were not considered candidates for CT scanning. The value of the protocol and CT scanning procedure itself was evident by the high yield of positive results (74% of the patients studied). Of the 12 children with urologic trauma, 2 had severe renal injuries that were not suspected by infusion i.v. pyelography and in one instance by arteriography. The magnitude and extent of perirenal hemorrhage was easily demonstrated. Thirteen patients had splenic lacerations, while 7 children had suspected hepatic injuries all accurately demonstrated by CT scans. Intra-peritoneal blood was easily detected. Two patients had pancreaticoduodenal injuries. Eleven of 12 renal injuries, 9 of 13 splenic lacerations, 5 of 7 hepatic injuries, and both pancreaticoduodenal injuries were successfully treated nonoperatively. The appropriateness of conservative management was substantiated by periodic follow-up examinations. This study demonstrated the improved sensitivity of CT scanning and ability to visualize intra- and retroperitoneal structures simultaneously when compared to more conventional methods of radiographic evaluation. The applications of CT scanning in the evaluation of the traumatized patient reduces the number of ancillary tests required for diagnosis, provides more accurate information regarding the extent and severity of the injury, and results in more appropriate decisions regarding the need for exploration versus nonoperative management. In addition, this modality offers an accurate method for long-term follow-up, allowing definitive recommendations concerning activities.