An Evolving Clinical Need: Discordant Oxygenation Measurements of Intubated COVID-19 Patients.

Since the first appearance of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) earlier this year, clinicians and researchers alike have been faced with dynamic, daily challenges of recognizing, understanding, and treating the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Those who are moderately to severely ill with COVID-19 are likely to develop acute hypoxemic respiratory failure and require administration of supplemental oxygen. Assessing the need to initiate or titrate oxygen therapy is largely dependent on evaluating the patient's existing blood oxygenation status, either by direct arterial blood sampling or by transcutaneous arterial oxygen saturation monitoring, also referred to as pulse oximetry. While the sampling of arterial blood for measurement of dissolved gases provides a direct measurement, it is technically challenging to obtain, is painful to the patient, and can be time and resource intensive. Pulse oximetry allows for non-invasive, real-time, continuous monitoring of the percent of hemoglobin molecules that are saturated with oxygen, and usually closely predicts the arterial oxygen content. As such, it was particularly concerning when patients with severe COVID-19 requiring endotracheal intubation and mechanical ventilation within one of our intensive care units were observed to have significant discordance between their predicted arterial oxygen content via pulse oximetry and their actual measured oxygen content. We offer these preliminary observations along with our speculative causes as a timely, urgent clinical need. In the setting of a COVID-19 intensive care unit, entering a patient room to obtain a fresh arterial blood gas sample not only takes exponentially longer to do given the time required for donning and doffing of personal protective equipment (PPE), it involves the consumption of already sparce PPE, and it increases the risk of viral exposure to the nurse, physician, or respiratory therapist entering the room to obtain the sample. As such, technology similar to pulse oximetry which can be applied to a patients finger, and then continuously monitored from outside the room is essential in preventing a particularly dangerous situation of unrealized hypoxia in this critically-ill patient population. Additionally, it would appear that conventional two-wavelength pulse oximetry may not accurately predict the arterial oxygen content of blood in these patients. This discordance of oxygenation measurements poses a critical concern in the evaluation and management of the acute hypoxemic respiratory failure seen in patients with COVID-19.

Clinical impact of rapid influenza PCR in the adult emergency department on patient management, ED length of stay, and nosocomial infection rate.

BACKGROUND: Seasonal influenza causes significant morbidity and mortality and incurs large economic costs. Influenza like illness is a common presenting concern to Emergency Departments (ED), and optimizing the diagnosis of influenza in the ED has the potential to positively affect patient management and outcomes. Therapeutic guidelines have been established to identify which patients most likely will benefit from anti-viral therapy. OBJECTIVES: We assessed the impact of rapid influenza PCR testing of ED patients on laboratory result generation and patient management across two influenza seasons. METHODS: A pre-post study was performed following a multifaceted clinical redesign including the implementation of rapid influenza PCR at three diverse EDs comparing the 2016-2017 and 2017-2018 influenza seasons. Testing parameters including turn-around-time and diagnostic efficiency were measured along with rates of bed transfers, hospital-acquired (HA) influenza, and ED length of stay (LOS). RESULTS: More testing of discharged patients was performed in the post-intervention period, but influenza rates were the same. Identification of influenza-positive patients was significantly faster, and there was faster and more appropriate prescription of anti-influenza medication. There were no differences in bed transfer rates or HA influenza, but ED LOS was reduced by 74 minutes following clinical redesign. CONCLUSIONS: Multifaceted clinical redesign to optimize ED workflow incorporating rapid influenza PCR testing can be successfully deployed across different ED environments. Adoption of rapid influenza PCR can streamline testing and improve antiviral stewardship and ED workflow including reducing LOS. Further study is needed to determine if other outcomes including bed transfers and rates of HA influenza can be affected by improved testing practices.

Development of an Emergency Department Trigger Tool Using a Systematic Search and Modified Delphi Process.

OBJECTIVE: This study aimed to develop an emergency department (ED) trigger tool to improve the identification of adverse events in the ED and that can be used to direct patient safety and quality improvement. This work describes the first step toward the development of an ED all-cause harm measurement tool by experts in the field. METHODS: We identified a multidisciplinary group of emergency medicine safety experts from whom we solicited candidate triggers. We then conducted a modified Delphi process consisting of 4 stages as follows: (1) a systematic literature search and review, including an independent oversampling of review for inclusion, (2) solicitation of empiric triggers from participants, (3) a Web-based survey ranking triggers on specific performance constructs, and (4) a final in-person meeting to arrive at consensus triggers for testing. Results of each step were shared with participants between each stage. RESULTS: Among an initial 804 unique articles found using our search criteria, we identified 94 that were suitable for further review. Interrater reliability was high (κ = 0.80). Review of these articles yielded 56 candidate triggers. These were supplemented by 58 participant-submitted triggers yielding a total of 114 candidate triggers that were shared with team members electronically along with their definitions. Team members then voted on each measure via a Web-based survey, ranking triggers on their face validity, utility for quality improvement, and fidelity (sensitivity/specificity). Participants were also provided the ability to flag any trigger about which they had questions or they felt merited further discussion at the in-person meeting. Triggers were ranked by combining the first 2 categories (face validity and utility), and information on fidelity was reviewed for decision making at the in-person meeting. Seven redundant triggers were eliminated. At an in-person meeting including representatives from all facilities, we presented the 50 top-ranked triggers as well as those that were flagged on the survey by 2 or more participants. We reviewed each trigger individually, identifying 41 triggers about which there was a clear agreement for inclusion. Of the seven additional triggers that required subsequent voting via e-mail, 5 were adopted, arriving at a total of 46 consensus-derived triggers. CONCLUSIONS: Our modified Delphi process resulted in the identification of 46 final triggers for the detection of adverse events among ED patients. These triggers should be pilot field tested to quantify their individual and collective performance in detecting all-cause harm to ED patients.

Impact of Type and Number of Complications on Mortality in Admitted Elderly Blunt Trauma Patients.

BACKGROUND: Advanced age and comorbidities are recognized risk factors for adverse outcomes in elderly trauma patients. However, the contribution of the number and type of complications to in-hospital mortality in elderly blunt trauma admissions has not been extensively studied. METHODS: A retrospective review of the trauma registry at a level 1 trauma center for blunt trauma patients age ≥65 y hospitalized for at least 2 d between 2010 and 2015. RESULTS: There were 2467 admissions, with a median age of 81 y and median injury severity score of 9. The most common mechanism of injury was a low-level fall. Approximately 19.6% of admissions had a complication: 11.1% major complications, 8.6% other complications. The in-hospital mortality rate was significantly different (P < 0.001) among the three groups at 16.1% of major complications group, 7.1% of other, and 2.1% of no complications (P < 0.001). On multivariate logistic regression, each major complication increased the odds for in-hospital mortality by 1.59-fold. CONCLUSIONS: Complications are not infrequent in elderly blunt trauma admissions, despite a generally lower energy mechanism of injury. Each major complication is associated with increased odds of mortality. Multifaceted interventions for prevention and mitigation of complications are indicated.

Risk assessment of the blunt trauma victim: The role of the quick Sequential Organ Failure Assessment Score (qSOFA).

BACKGROUND: A number or risk assessment tools are used in trauma victims. Because of its simplicity, we examined the ability of the recently described quick Sequential Organ Failure Assessment Score (qSOFA) to predict outcomes in blunt trauma patients presenting to the Emergency Department. METHODS: We queried the trauma registry at a Level 1 Trauma Center for all adult blunt trauma admissions between 1/1/10 and 9/30/15. qSOFA scores were the sum of binary scores for 3 variables (RR ≥ 22, SBP≤100 mmHg, and GCS≤13). RESULTS: There were 7064 admissions (5664 admissions had qSOFA = 0, 1164 had qSOFA = 1, 223 had qSOFA = 2, and 13 had qSOFA = 3). Higher qSOFA scores were associated with greater injury severity, increased ICU admission, and higher complication rates. qSOFA scores were associated with in-hospital mortality (1.7% with qSOFA = 0; 8.7% with qSOFA = 1; 22.4% with qSOFA = 2; 23.1% with qSOFA = 3; p < 0.001). On multivariate analysis, qSOFA score was an independent predictor of mortality. CONCLUSIONS: qSOFA scores are directly associated with adverse outcomes in blunt trauma victims.

Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes.

OBJECTIVES: To evaluate the incidence of spinal fractures and their outcomes in the elderly who fall from low-levels in a suburban county. DESIGN: Retrospective county-wide trauma registry review from 2004 to 2013. SETTING: Suburban county with regionalized trauma care consisting of 11 hospitals. PARTICIPANTS: Adult trauma patients aged ≥65 years who were admitted after falling from <3 feet. MEASUREMENTS: Demographic characteristics, comorbidities, and outcomes. RESULTS: Spinal fractures occurred in 18% of 4,202 older adult patients admitted following trauma over this 10-year time period, in the following distribution: 43% cervical spine, 5.7% thoracic, 4.9% lumbar spine, 36% sacrococcygeal, and 9.6% multiple spinal regions. As compared to non-spinal fracture patients, more spinal fracture patients went to acute/subacute rehabilitation (47% vs 34%, P < .001) and fewer were discharged home (21% vs 35%, P < .001). In-hospital mortality rate in spinal and non-spinal fracture patients was similar (8.5% vs 9.3%, P = .5). CONCLUSION: Low-level falls often resulted in a spinal fracture at a variety of levels. Vigilance in evaluation of the entire spine in this population is suggested.

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma.

BACKGROUND: The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown. METHODS: The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed. RESULTS: Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality. CONCLUSIONS: Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.

Unplanned intensive care unit admission following trauma.

BACKGROUND: The prevalence and outcomes of trauma patients requiring an unplanned return to the intensive care unit (ICU) and those initially admitted to a step-down unit or floor and subsequently upgraded to the ICU, collectively termed unplanned ICU (UP-ICU) admission, are largely unknown. METHODS: A retrospective review of the trauma registry of a suburban regional trauma center was conducted for adult patients who were admitted between 2007 and 2013, focusing on patients requiring ICU admission. Prehospital or emergency department intubations and patients undergoing surgery immediately after emergency room evaluation were excluded. RESULTS: Of 5411 admissions, there were 212 UP-ICU admissions, 541 planned ICU (PL-ICU) admissions, and 4658 that were never admitted to the ICU (NO-ICU). Of the 212 UP-ICU admits, 19.8% were unplanned readmissions to the ICU. Injury Severity Score was significantly different between PL-ICU (16), UP-ICU (13), and NO-ICU (9) admits. UP-ICU patients had significantly more often major (Abbreviated Injury Score ≥ 3) head/neck injury (46.7%) and abdominal injury (9.0%) than the NO-ICU group (22.5%, 3.4%), but significantly less often head/neck (59.5%) and abdominal injuries (17.9%) than PL-ICU patients. Major chest injury in the UP-ICU group (27.8%) occurred at a statistically comparable rate to PL-ICU group (31.6%) but more often than the NO-ICU group (14.7%). UP-ICU patients also significantly more often underwent major neurosurgical (10.4% vs 0.7%), thoracic (0.9% vs 0.1%), and abdominal surgery (8.5% vs 0.4%) than NO-ICU patients. Meanwhile, the PL-ICU group had statistically comparable rates of neurosurgical (6.8%) and thoracic surgical (0.9%) procedures but lower major abdominal surgery rate (2.0%) than the UP-ICU group. UP-ICU admission occurred at a median of 2 days following admission. UP-ICU median hospital LOS (15 days), need for mechanical ventilation (50.9%), and in-hospital mortality (18.4%) were significantly higher than those in the PL-ICU (9 days, 13.9%, 5.4%) and NO-ICU (5 days, 0%, 0.5%) groups. CONCLUSIONS: UP-ICU admission, although infrequent, was associated with significantly greater hospital length of stay, rate of major abdominal surgery, need for mechanical ventilation, and mortality rates than PL-ICU and NO-ICU admission groups.

Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury.

BACKGROUND: Do Not Resuscitate (DNR) orders have been associated with poor outcomes in surgical patients. There is limited literature on admitted trauma patients with advanced directives indicating DNR status before admission (preadmission DNR [PADNR]). METHODS: A retrospective review of the trauma registry of a suburban county was carried out for admitted trauma patients with age ≥41 years, who were admitted between 2008 and 2013. RESULTS: Of 7,937 admitted patients, 327 had a preadmission advanced directive indicating DNR. PADNR patients were significantly older (87 vs 69 years), with more frequent comorbidities, and were more often admitted after a fall (94.2% vs 65.8%). PADNR patients had a higher Injury Severity Score (14 vs 11). They also had significantly increased rates of pneumonia, sepsis, myocardial infarction, and death (33.6% vs 5.9%). On multivariate logistic regression, the presence of a preadmission advanced directive indicating DNR status was independently associated with a 5.2-fold increased odds of mortality. CONCLUSION: An advanced directive indicating DNR is associated with adverse outcomes following trauma.

Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.

BACKGROUND: The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes. METHODS: A retrospective review of a county's trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated. RESULTS: A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21-41] vs. 22 [16-29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18-45] vs. 26 [16-44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001). CONCLUSION: A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center.

BACKGROUND: There is limited literature on early unplanned hospital readmission after acute traumatic injury, especially at suburban facilities. METHODS: A retrospective review of the trauma registry at a suburban, state-designated, level-I academic trauma center from July 2009 to June 2012 was performed for all admitted (≥24 hours) adult (age ≥18 years) trauma patients who were discharged alive, including unplanned readmissions within 30 days of discharge. RESULTS: Of 3,622 admitted adult trauma patients, 6.57% were readmitted at a median of 9 days. Major surgery was required in 15.9% patients on readmission. The mortality rate at readmission was 4.6%. Multiple factors were associated with readmission on univariate analysis; however, on multivariate analysis, only major comorbidities (odds ratio [OR], 1.53), hospital length of stay (OR, 1.01), abdominal Abbreviated Injury Score greater than or equal to 3 (OR, 2.10), and discharge to a skilled nursing facility or subacute facility (OR, 1.56) were significant predictors. Meanwhile, index admission to surgical services was associated with a significantly lower readmission risk (OR, .60). CONCLUSIONS: Trauma patients are infrequently readmitted. Index admission to a surgical service reduces the risk of readmission. Earlier medical follow-up should be considered.

Trends in clinical presentation, management, and mortality of blunt aortic traumatic injury over an 18-year period.

BACKGROUND: The purpose of our study was to assess whether the trends in management of blunt thoracic aortic injury (BTAI) have changed its outcomes over the years. METHODS: We reviewed data of 88 (0.3%) adult patients with BTAI from January 1993 to December 2010. Primary end points were trends in presentation and time to repair and early morbidity and mortality. RESULTS: Of all, 63 (72%) patients with BTAI were male (age, 38 ± 17). The yearly distribution of cases and severity of associated injuries remain stable. Of all, 16 (21%) patients had no intervention, 47 (63%) underwent open repair, and 12 (16%) underwent endovascular treatment. The postoperative mortality has decreased from 29% to 9% and the time from presentation to repair has increased from 6 to 14 hours during the study period. CONCLUSIONS: The incidence of BTAI remains stable with a reduction in postoperative mortality rate and an increasing number of delayed interventions over the past 18 years.

The relationship between annual hospital volume of trauma patients and in-hospital mortality in New York State.

BACKGROUND: Several studies in the literature have examined the volume-outcome relationship for trauma, but the findings have been mixed, and the associated impact of the trauma center level has not been examined to date. The purposes of this study are to (1) determine whether there is a significant relationship between the annual volume of trauma inpatients treated in a trauma center (with "patients" defined in multiple ways) and short-term mortality of those patients, and (2) examine the impact on the volume-mortality relationship of being a Level I versus Level II trauma center. METHODS: Data from New York's Trauma Registry in 2003 to 2006 were used to examine the impact of total trauma patient volume and volume of patients with Injury Severity Score (ISS) of at least 16 on in-hospital mortality rates after adjusting for numerous risk factors that have been demonstrated to be associated with mortality. RESULTS: The adjusted odds of in-hospital mortality patients in centers with a mean annual volume of less than 2,000 patients was significantly higher (adjusted odds ratio = 1.46, 95% confidence interval, 1.25-1.71) than the odds for patients in higher volume centers. The adjusted odds of mortality for patients in centers with an American College of Surgeons-recommended annual volume of less than 240 patients with an ISS of at least 16 was 1.41 times as high (95% confidence interval, 1.17-1.69) as the odds for patients in higher volume centers. However, for both volume cohorts analyzed, the variation in risk-adjusted in-hospital mortality rate was greater among centers within each volume subset than between these volume subsets. CONCLUSION: When considering the trauma system as a whole, higher total annual trauma center volume (2,000 or higher) and higher volume of patients with ISS ≥16 (240 and higher) are significant predictors of lower in-hospital mortality. Although the American College of Surgeons-recommended 1,200 total volume is not a significant predictor, hospitals in New York with ISS ≥16 volumes in excess of 240 also have total volumes in excess of 2,000. However, when considering individual trauma centers, high volume centers do not consistently perform better than low volume centers. Thus, despite the association between volume and mortality, we believe that the most accurate way to assess trauma center performance is through the use of an accurate, complete, comprehensive database for computing center-specific risk-adjusted mortality rates, rather than volume per se.

Phytobezoar as a cause of intestinal obstruction.

INTRODUCTION: A small bowel phytobezoar is a rare cause of intestinal obstruction, whose most common cause is adhesion. CASE REPORT: This is a case report in which the etiology of small bowel obstruction was identified due to intussusception via computed tomography scan, and upon exploration, was found to be due to a small bowel phytobezoar.

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report.

The present article reports on the successful management of a large flail chest with traumatic pulmonary herniation in a patient who could not be weaned from mechanical ventilation following a course of conservative management. Surgical intervention involved open reduction and internal fixation with tubular plates to stabilize the flail segment, followed by a pectoralis major myocutaneous flap to repair the chest wall defect. Following surgical intervention, the patient was able to be weaned from mechanical ventilation and showed remarkable improvement in pulmonary function parameters. To the authors' knowledge, the present report is the first to describe the use of open reduction and internal fixation of the chest wall and flap reconstruction to treat lung herniation with a flail chest segment.

Training and certification in surgical critical care: a position paper by the Surgical Critical Care Program Directors Society.

Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.

Ventilator-associated pneumonia in pediatric trauma patients.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality in adult trauma patients. No study has characterized VAP in pediatric trauma patients. We determined the rates of and potential risk factors for VAP in pediatric trauma patients. METHODS: A countywide trauma registry identified all pediatric trauma patients with potential VAP treated at a Regional Trauma Center. After a structured chart review, descriptive statistics were used to characterize the population. RESULTS: One hundred fifty-eight trauma patients younger than 16 years requiring intubation and mechanical ventilation were identified in 3388 pediatric trauma admissions from the period 1995-2006. Drownings and poisonings were excluded. The registry identified 14 potential VAPs, of which, on detailed review, 7 were true cases. The VAP rate for pediatric trauma patients was 0.2% overall or 4.4% of those mechanically ventilated. In addition, ventilator days were available in the registry from 2003 forward and the rate in ventilator days was found to be 13.83/1000. Although higher than the overall pediatric intensive care unit VAP rate (5.93/1000 ventilator days), the pediatric trauma VAP rate was substantially lower than the VAP rate in adult trauma patients (58.25/1000 ventilator days). On chart review, six of the seven patients were male and older than 10 years (mean age, 11.9 years). All seven patients with VAP were blunt trauma victims with head injury (mean initial Glasgow Coma Score, 5.6) with Injury Severity Scores over 25 (mean, 32.1). Pulmonary contusion was present in four of the seven. Although the in-hospital mortality rate of ventilated pediatric trauma patients was 17.1%, there was no mortality in those with VAP. CONCLUSIONS: The rate of VAP in pediatric trauma patients is substantially lower than in similar adults. Age older than 10 years, blunt trauma, head injury, and Injury Severity Score >25 may be risk factors. VAP is not associated with increased mortality in pediatric trauma patients.