Initial prehospital Rapid Emergency Medicine Score (REMS) to predict outcomes for COVID-19 patients.

OBJECTIVE: The Rapid Emergency Medicine Score (REMS) has not been widely studied for use in predicting outcomes of COVID-19 patients encountered in the prehospital setting. This study aimed to determine whether the first prehospital REMS could predict emergency department and hospital dispositions for COVID-19 patients transported by emergency medical services. METHODS: This retrospective study used linked prehospital and hospital records from the ESO Data Collaborative for all 911-initiated transports of patients with hospital COVID-19 diagnoses from July 1 to December 31, 2020. We calculated REMS with the first recorded prehospital values for each component. We calculated area under the receiver operating curve (AUROC) for emergency department (ED) mortality, ED discharge, hospital mortality, and hospital length of stay (LOS). We determined optimal REMS cut-points using test characteristic curves. RESULTS: Among 13,830 included COVID-19 patients, median REMS was 6 (interquartile range [IQR]: 5-9). ED mortality was <1% (n = 80). REMS ≥9 predicted ED death (AUROC 0.79). One-quarter of patients (n = 3,419) were discharged from the ED with an optimal REMS cut-point of ≤5 (AUROC 0.72). Eighteen percent (n = 1,742) of admitted patients died. REMS ≥8 optimally predicted hospital mortality (AUROC 0.72). Median hospital LOS was 8.3 days (IQR: 4.1-14.8 days). REMS ≥7 predicted hospitalizations ≥3 days (AUROC 0.62). CONCLUSION: Initial prehospital REMS was modestly predictive of ED and hospital dispositions for patients with COVID-19. Prediction was stronger for outcomes more proximate to the first set of emergency medical services (EMS) vital signs. These findings highlight the potential value of first prehospital REMS for risk stratification of individual patients and system surveillance for resource planning related to COVID-19.

COVID-19 Preliminary Case Series: Characteristics of EMS Encounters with Linked Hospital Diagnoses.

BACKGROUND: Few studies have examined the prehospital presentation, assessment, or treatment of patients diagnosed with coronavirus disease 2019 (COVID-19). The objective of this preliminary report is to describe prehospital encounters for patients with a COVID-19 hospital diagnosis and/or COVID-19 EMS suspicion versus those with neither a hospital diagnosis nor EMS suspicion of the disease. METHODS: This case series evaluated electronic patient care records from EMS agencies participating in a large national bi-directional data exchange. All records for 9-1-1 responses between March 1 and April 19, 2020, resulting in transport to a hospital, with at least one ICD-10 outcome returned via the data exchange were included. Hospital ICD-10 codes used to determine COVID-19 diagnoses included B97.2, B97.21, B97.29, B34.2, and U07.1. COVID-19 EMS suspicion was defined as a documented EMS primary or secondary impression of COVID-19, or indication of COVID-19 suspicion in the prehospital free-text narrative. Comparisons were stratified by COVID-19 hospital diagnosis and COVID-19 EMS suspicion. Descriptive and comparative statistics are presented. RESULTS: There were 84,540 EMS patient records with linked hospital ICD-10 codes included. Of those, 814 (1%) patients had a COVID-19 hospital diagnosis. Overall, COVID-19 EMS suspicion was documented for 3,204 (4%) patients. A COVID-19 EMS suspicion was documented for 636 (78%) of hospital diagnosed COVID-19 patients. Those with COVID-19 hospital diagnoses were more likely to present with tachycardia, tachypnea, hypoxia, and fever during the EMS encounter. EMS responses for patients diagnosed with COVID-19 were also more likely to originate from a skilled nursing/assisted living facility. EMS PPE (eye protection, mask, or gown) use was more frequently documented on records of patients who had hospital diagnosed COVID-19. CONCLUSION: In this large sample of prehospital encounters, EMS COVID-19 suspicion demonstrated sensitivity of 78% and positive predictive value of 20% compared with hospital ICD-10 codes. These data indicate that EMS suspicion alone is insufficient to determine appropriate utilization of PPE.

Donor site healing dynamics: molecular, histological, and noninvasive imaging assessment in a porcine model.

Understanding the physiology of donor site healing will lead to advances in how these wounds are treated and may ultimately allow faster healing, more frequent autografting, and more effective care of the burn-injured patient. Unfortunately, a paucity of data exists regarding perfusion metrics over the course of donor site healing. Furthermore, there are no studies that interrelate indices of perfusion with the molecular and cellular processes of donor site healing. Male Duroc pigs were anesthetized and donor site wounds were created using a Zimmer dermatome at a depth of 0.060 inch (1.52 mm). Digital photographs, laser Doppler images, and punch biopsies were obtained before and after excision and on days 2, 4, 7, 9, 11, 14, and 16 until wounds were healed. RNA isolation was performed and quantitative polymerase chain reaction was used to examine differential gene expression over the time course. Formalin-fixed biopsies were embedded in paraffin, sectioned, stained, and examined. Wound surfaces were 83% re-epithelialized by day 16. Perfusion peaked on day 2 then declined, but it remained significantly elevated compared to before excision (P < .05). From day 9 onward, mean perfusion units were not significantly different from baseline (P < .05). Twenty-two representative genes were selected for examination. RNA expression of collagen, tenascin-cytoactin, inflammatory cytokines, remodeling enzymes, growth factors, and Wnt was increased. Inflammatory cells and cytokines were demonstrated histologically. Nuclei per high powered field peaked at day 7 and neodermal thickness increased daily to day 14. A novel porcine model for donor site wound healing that interrelates re-epithelilaizationand perfusion with molecular and cellular indices has been demonstrated.

Comparing a single institution's experience with electrical injuries to the data recorded in the National Burn Repository.

Electrical injuries usually represent a small proportion of a burn center's admissions. Although burn size may be small, internal tissue damage is sometimes extensive. This study reviews a single institution's experience with electrical injuries and compares it to the multi-institutional data of the National Burn Repository (NBR). The 2009 NBR and the records of a large urban burn center (single institution) were queried for adult electrical injuries over an 8-year period. Data examined included demographics, %TBSA burn, length of stay (LOS), injury circumstance, and disposition. Multiple linear regression models were created to determine factors related to LOS. One hundred ninety-one single-institution patients and 2837 multi-institution patients met the criteria. Both cohorts were mostly white males approximately 30 years of age and injuries where often work-related. Single-institution patients had a mean injury size of 4% TBSA, while multi-institution patients had 7%. The most common exposure source was domestic wiring for single-institution patients and electrical power plants/lines for multi-institution patients. Single-institution data showed that females had a shorter LOS than males (P < .0001). Single-institution data showed that independent risk factors for an increased LOS were infection, amputation, fasciotomy, and being Hispanic. Independent risk factors for multi-institution patients were being Hispanic and large %TBSA burn. There was no difference in mortality, gender, age, LOS, or intensive care unit LOS between the cohorts. In this analysis, there was no statistical difference between outcomes in the single- or multi-institutional groups. However, injuries reported in the NBR were slightly larger. In both cohorts, an increase in LOS was associated with %TBSA, as expected. Interestingly, Hispanic ethnicity correlated with an increased LOS. Future work will be aimed at understanding this correlation to determine whether it is specific to electrical injury or burns in general.

Early serum (1→3)-ß-D-glucan levels in patients with burn injury.

Serum (1→3)-ß-D-glucan (BG) is increasingly used as diagnostic marker for invasive fungal infections. Exposure to gauze may lead to false-positive BG assays. The role of BG is unclear in thermally injured patients who frequently require extensive gauze coverage; therefore, we prospectively evaluated BG levels in burn-injured patients. Serum BG levels were measured in 18 burn patients immediately before application of the first dressing and 12 h after. Patients were stratified by extent of total body surface area (TBSA) requiring gauze coverage: <20%, 20-39%, 40-60% and >60%. BG levels were obtained from patients with non-burn trauma as controls. BG results were positive (>80 pg ml⁻¹) in 9/18 (50%) patients at baseline and in 8/18 (44%) 12 h after application of the first dressing. BG levels were positive in 1/5 (20%) of patients with <20% TBSA requiring gauze and in 10/13 (77%) with ≥ 20% (P < 0.05). None of the control patients had positive BG at any time point and none of the patients had candidemia at baseline. Mean serum BG levels decreased (19.44 pg ml⁻¹) after gauze placement. False-positive serum BG elevations are common in this patient population. Positivity correlates with extent of TBSA injured, but is not impacted by the gauze itself.

When a hero becomes a patient: firefighter burn injuries in the National Burn Repository.

Firefighters receive significant training and are outfitted with state-of-the-art protective equipment. However, given the unpredictable nature of their work environment, injuries still occur. The National Burn Repository (NBR) was viewed as a resource for defining the epidemiology of these injuries on a national level and to identify predictive factors for outcomes in this population. The NBR was queried for the occupation of "firefighter" for the years 1990-2008. Records were screened for completeness, and 597 patients were identified for analysis. Data examined included demographics, %TBSA burn, length of stay (LOS), injury circumstance, and disposition. Multiple linear regression models were created to determine factors related to outcome measures. The majority of patients were white (84%) and male (96%). The mean age was 35 years. Most injuries were caused by fire/flame (73%). Only six deaths (1%) were reported. Most injuries were work-related (86%), and most patients were discharged home (92%). Inhalation injury was documented in 9% of patients. The mean LOS was 6.5 ± 11.3 days (median 2 days), and few patients had critical care requirements. The average %TBSA was 6 ± 11.7%. Patients with larger injuries had increased LOS. The presence of inhalation injury, elevated carboxyhemoglobin levels, and advancing age were significantly associated with larger burns. From the NBR data, most firefighter burn injuries were small, and few firefighter burn patients required critical care resources or had significant disability. Firefighters comprise a small number of burn center admissions each year, yet they are an important population to consider for burn prevention efforts.

The results of a national survey regarding nutritional care of obese burn patients.

Little is known about the nutritional needs of obese burn patients. Given the impact of obesity on the morbidity and mortality of these patients, a uniform understanding of perceptions and practices is needed. To elucidate current practices of clinicians working with the obese burn population, the authors constructed a multidisciplinary survey designed to collect this information from practitioners in United States burn centers. An electronic approach was implemented to allow for ease of distribution and completion. A portable document format (pdf) letter was e-mailed to the members of the American Burn Association and then mailed separately to additional registered dietitians identified as working in burn centers. This letter contained a link to a 29-question survey on the SurveyMonkey.com server. Questions took the form of multiple choice and free text entry. Responses were received from physicians, mid-level practitioners, registered dietitians, and nurses. Seventy-five percent of respondents defined obesity as body mass index >30. The Harris-Benedict equation was identified as the most frequently used equation to calculate the caloric needs of burn patients (32%). Fifty-eight percent indicated that they alter their calculations for the obese patient by using adjusted body weight. Calculations for estimated protein needs varied among centers. The majority did not use hypocaloric formulas for obese patients (79%). Enteral nutrition was initiated within the first 24 hours for both obese and nonobese patients at most centers. Sixty-three percent suspend enteral nutrition during operative procedures for all patients. Oral feeding of obese patients was the most preferred route, with total parenteral nutrition being the least preferred. Longer length of stay, poor wound healing, poor graft take, and prolonged intubation were outcomes perceived to occur more in the obese burn population. In the absence of supporting research, clinicians are making adjustments to the nutritional care of obese burn patients. This indicates the need for further research to determine consistent best practices.

Incidence of methemoglobinemia in patients receiving cerium nitrate and silver sulfadiazine for the treatment of burn wounds: a burn center's experience.

In 1976, the combination of cerium nitrate and silver sulfadiazine was introduced as a topical therapy for burn wounds. Experience with a locally prepared combination agent has shown physical change of the eschar and delayed subeschar bacterial colonization. A potential systemic complication of this treatment is the development of methemoglobinemia (Met-Hba) due to the oxidizing nature of Ce(NO(3))(3). Met-Hba has a spectrum of clinical consequences, ranging from headache and cyanosis to cardiac ischemia, hypotension, and even death. Given the frequent use of this combination agent at our burn center, a retrospective review was conducted to evaluate the incidence of Met-Hba. A query of pharmacy records revealed 170 patients from January 2005 to October 2009 that had received this treatment. Eighteen patients (∼10%) developed Met-Hba as noted on arterial blood gas (methemoglobin>3%) and only three patients (∼2%) had methemoglobin levels >10%. In the majority of cases, there were no clinical symptoms of Met-Hba. Most patients' relative hypoxia resolved with cessation of treatment; however, five patients required treatment with methylene blue. The presence of Met-Hba associated with this topical therapy can be diagnosed early by vigilant monitoring, thereby reducing morbidity and mortality. In our experience, cerium combined with silver sulfadiazine is a valuable and safe treatment for deep partial and full-thickness burn wounds.

Management of fasciotomy wounds--does the dressing matter?

Fasciotomy is a limb-saving procedure in the management of ischemic extremities. Little evidence exists as to the best method of fasciotomy wound management. We hypothesized that the use of vacuum dressing (VAC) or creation of dynamic tension (DYN) would increase rates of primary closure, reducing the need for split thickness skin grafting (STSG). The records of a large urban Level I trauma center were used to identify fasciotomy recipients over a 10-year period and were retrospectively analyzed. Data collected included injury characteristics, wound management, and outcomes. Wound management was dictated by surgeon preference, and categorized as gauze packing, DYN, or VAC. The primary outcome was primary closure versus need for STSG. Wound management cohorts were compared using logistic regression. Fisher's exact test and χ(2) were performed to compare proportions and categorical variables respectively. From 2000 to 2009, 227 patients had a fasciotomy performed. Mechanism, age, and incidence of fracture were different between the groups. There was a trend towards increased primary closure with DYN (83%). Average length of stay (LOS) was 21 days for those receiving primary closure and 27 days for STSG. There was a significant decrease in LOS for the DYN group (average 16 days) when compared with gauze packing and VAC. In this series of 227 patients who underwent fasciotomy, no technique of wound management produced a significant improvement in primary closure rate. A trend toward more primary closure was seen in the DYN group. LOS was longer for patients receiving STSG. The DYN cohort had a significantly shorter LOS.