ABSTRACT
Study Objective: The SARS-CoV-2 (COVID-19) pandemic significantly impacted emergency department volume and acuity. The Delta and Omicron variants contributed to additional surges. We describe the impact that the initial pandemic phase had on frequency and severity of typically non-life-threatening emergencies using upper extremity injuries as a model for other potentially emergent presentation as compared to pre-pandemic times. We do this using the epidemiology of pre-defined significant upper extremity injuries at our facility as a specific example of what occurred at an urban trauma center. Methods: We conducted a comparison of two 6-month periods: between March 2019 and August 2019 (prior to COVID-19) and between March 2020 and August 2020 after the onset of the initial COVID-19 wave. We performed a retrospective chart review of patients who presented with upper extremity injury chief complaints using analysis of the electronic medical record at a single urban tertiary care trauma center in the Midwestern United States. We investigated examination findings, imaging, frequency of surgical procedures and final diagnosis. Results: In the 2019 study period, there were 31,157 ED patients, including 429 with upper extremity injuries, of which 108 patients had significant injuries. In the 2020 study period, there were 24,295 patient presentations, of which 118 of 296 upper extremity presentations were significant. We a priori defined significant injury as follows: fractures, dislocations, neurovascular injuries, or need for operative intervention within 24 hours of ED presentation. Specifically, 25.2% of injuries were significant pre-COVID-19 and 39.9% (p < 0.001) during the initial COVID-19 surge. The absolute number and percentage of significant injuries increased from pre-COVID-19 compared to the initial COVID-19 surge despite an overall 22% decrease in total patient volume. Conclusion: The incidence of significant upper extremity musculoskeletal injuries increased during the pandemic even though the overall number of ED presentations for upper extremity musculoskeletal injuries decreased.
ABSTRACT
BACKGROUND: Vitamin K antagonist (VKA) reversal in patients with acute major bleeding and coagulopathy is an example of an urgent intervention in the emergency department. Intravenous (IV) prothrombin complex concentrate (PCC) may reverse VKA-induced coagulopathy in <30 min. In patients lacking IV access, effective PCC administration becomes problematic. No previous case reports have documented PCC infusion via intraosseous (IO) or alternative routes in this setting. CASE REPORT: A 74-year-old man presented to the emergency department (ED) after a head injury, with sudden onset of left-sided facial droop, weakness, hypertension, and dizziness. Initial vital signs include blood pressure of 221/102 mm Hg, a heart rate of 75 beats/min, and oxygen saturation of 96% on room air. Warfarin 3 mg once daily was among his medications. His international normalized ratio (INR) was 3.9 with a computed tomography scan showing intraparenchymal hemorrhage in the right temporal lobe. Multiple attempts for IV access at various sites were unsuccessful. Therefore, IO access was established. Because of his prolonged prothrombin time, elevated INR, and intraparenchymal hemorrhage, the decision was made to use 4-factor PCC to reverse the supratherapeutic INR. The INR normalized as an emergent right parietal hematoma evacuation was performed. After an inpatient course, the patient was eventually discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VKAs, like warfarin, are commonly prescribed medications. When life-threatening hemorrhage is present, rapid reversal of a VKA-induced coagulopathy may be a life-saving therapy. In the event that IV access has not been established, we have demonstrated that IO access is a viable alternative route for PCC administration.
