The Beirut Port Blast: spectrum of injuries and clinical outcomes at a large tertiary care center in Beirut, Lebanon.

PURPOSE: To describe injuries and outcomes of casualties of Beirut Port Blast treated at a large tertiary care center in Beirut, Lebanon. METHODS: A retrospective observational study assessing the spectrum of injuries, treatment, and medical outcome among casualties of the Beirut Port Blast, immediately after the blast and up to 1 week from the blast to the emergency department of the American University of Beirut Medical Center (AUBMC). RESULTS: A total of 359 patients were included. Most (n = 343, 95.6%) were adults (> 19 years), and males (56%) with a mean age of 42 ± 20 years. The most frequent mechanism of injury was a penetrating injury (45.7%), followed by other blast-related injuries (30.4%), and blunt injuries (23.4%). The most affected anatomical location were the limbs. Most (n = 217, 60.4%) patients required imaging. The most frequently administered medication was analgesics (38%), followed by anesthetics (35%), antibiotics (31%), tetanus vaccine (31%), and fluids (28%). Blood and blood products were administered in 3.8% of cases. Emergent procedures included endotracheal intubation (n = 18, 5%), surgical airway (n = 3, 0.8%), chest tube insertion (n = 4, 1.1%), thoracotomy (n = 1, 0.3%), and CPR (n = 5, 1.4%). A quarter of patients required surgical operations in the operating room (n = 85, 23.6%) and 18% required noncritical care admissions, 5.3% required critical care admissions, and 2.8% were dead on arrival. CONCLUSION: Casualties from this event had significant injuries requiring lifesaving interventions, surgical procedures, and admission to critical care units. High utilization of imaging modalities and of medications from existing stockpiles was also observed.

The prognostic value of the lactate/albumin ratio for predicting mortality in septic patients presenting to the emergency department: a prospective study.

OBJECTIVES: Lactate/albumin (L/A) ratio is a biomarker in sepsis that has been shown to outperform lactate. This prospective study aims to validate the superior prognostic value of the L/A ratio to lactate in sepsis and septic shock. METHODS: Prospective cohort conducted from September 2018 till February 2021 on adult patients presenting to the Emergency Department (ED) at a tertiary care centre with sepsis or septic shock. The primary outcome was the prognostic value of the L/A ratio compared to lactate with regards to mortality. RESULTS: A total of 939 septic patients were included throughout the study period. A total of 236 patients developed septic shock. The AUC value of the L/A ratio in septic patients was 0.65 (95% CI 0.61-0.70) and was higher than that of lactate alone 0.60 (95% CI 0.55-0.64) with a p < .0001. The optimal L/A ratio cut-off threshold that separated survivors from non-survivors was found to be 0.115 for all septic patients. The AUC of the L/A ratio was significantly higher for patients with a lactate ≥2 mmol/L: 0.69 (95% CI 0.64-0.74) versus 0.60 (95% CI 0.54-0.66) with a p < .0001 as well as for patients with an albumin level less than 30 g/L (AUC = 0.69 95% CI= 0.62-0.75 vs AUC= 0.66 95% CI= 0.59-0.73, p = .04). Among septic shock patients there was no statically significant difference in the AUC value of the L/A ratio compared to lactate (0.53 95% CI 0.45-0.61 vs 0.50 95% CI 0.43-0.58 respectively with a p-value = .11). CONCLUSIONS: The L/A ratio is a better predictor of in-patient mortality than lactate in sepsis patients. This superiority was not found in the septic shock subgroup. Our results encourage the use of the ratio early in the ED as a superior prognostic tool in sepsis patients.Key messagesWe aimed to assess the prognostic usefulness of the Lactate/Albumin ratio compared to lactate alone in septic and septic shock patients.The L/A ratio proved to be a better predictor of in-patient mortality than lactate alone in sepsis patients. This pattern also applies across various subgroups in our study (malignancy, diabetics, age above 65, lactate level less than 2 mmol/L, albumin less than 30 g/L). Our results favour the use of the L/A ratio over lactate alone in patients with sepsis and the previously mentioned subgroups.Our results do not favour the use of the ratio instead of lactate in septic shock patients as there was no statistically significant difference between the AUCs of the ratio and lactate alone.

Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?

BACKGROUND: Deep venous thrombosis (DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department (ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT. METHODS: This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital's electronic medical record. RESULTS: A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379 (15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT. CONCLUSIONS: Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

The prevalence and predictors of extended spectrum B-lactamase urinary tract infections among emergency department patients: A retrospective chart review.

BACKGROUND AND IMPORTANCE: Inadequate initial antibiotic treatment of ESBL urinary tract infections (UTI) can lead to increase in the number of antibiotics used, return visits, longer hospitalizations, increased morbidity and mortality and increased costs. Given the important health implications on patients, this study aimed to examine the prevalence and predictors of ESBL UTIs among Emergency Department (ED) patients of a tertiary care center in Beirut, Lebanon. DESIGN, SETTING AND PARTICIPANTS: Single-center retrospective observational study involving all adult UTI patients who presented to the ED of the American University of Beirut Medical Center, a tertiary care center between August 2019 and August 2020. RESULTS: Out of the 886 patients that were included, 24.9% had an ESBL organism identified by urine culture. They had higher bladder catheter use within the previous 90 days, antibiotic use within last 90 days, and were more likely to have a history of an ESBL producing isolate from any body site in the last year. Antibiotic use in the last 90 days and a history of ESBL producing isolate at any site in the previous year were significantly associated with developing an ESBL UTI (OR = 1.66, p = 0.001 and OR = 2.53, p < 0.001 respectively). Patients diagnosed with cystitis were less likely to have an ESBL organism (OR = 0.4 95%CI [0.20-0.81], p = 0.01) CONCLUSION: The prevalence of ESBL organisms was found to be 24.9% in urinary tract infections. The predictors of an ESBL UTI infection were antibiotic use in the last 90 days, a history of ESBL producing isolate at any site in the previous year. Based on the findings of our study, we can consider modifying initial empiric antibiotic treatment for patients presenting with a UTI with the above stated risk factors.

Characteristics and determinants of high-risk unscheduled return visits to the emergency department.

BACKGROUND: High-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED. METHODS: Case-control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation. RESULTS: Out of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75). CONCLUSION: HRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

The disease spectrum of adult patients at a tertiary care center emergency department in Lebanon.

OBJECTIVE: There is an increase in Emergency Department (ED) utilization globally. Understanding what patients present to EDs with is important for resource allocation, training and staffing purposes. There is paucity of data pertaining to ED visit presentations in Lebanon. This study aims at describing the spectrum of diseases among adult patients who present to a tertiary care center in Lebanon, an upper-middle income country (UMIC). METHODS: A retrospective chart review of adult patients (age ≥ 19) presenting to a tertiary care hospital ED during 2010-2011 was completed. Common diagnoses in three categories (all adult visits, treat and release, admitted visits) were assessed. Diagnoses were classified according to the Clinical Classifications Software. Descriptive statistics were presented in tables as frequencies and percentages. RESULTS: During the study period, 32787 adults presented to the ED with 18.7% resulting in hospital admission. The most common diagnoses in ED patients were injuries and conditions due to external causes, abdominal pain, non-specific chest pain and intestinal infections. In the treat and release group, intestinal infections emerged in the common list for ages 19-44. Coronary atherosclerosis was common in admitted patients aged ≥45 years. Summer was the busiest season, with abdominal pain and intestinal infection being prominent diagnoses during that season. CONCLUSIONS: This study is the first to assess adult ED visits in a Lebanese setting. Our study suggests that patients in our population suffer from the double burden of both communicable and non-communicable disease, with coronary atherosclerosis common in admitted patients (≥ 45 years) and intestinal infections common in treat and release adult patients (19-44years), the latter condition peaking in summer and driving seasonal surges in ED visits.