Gender disparity in stoke: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage.

OBJECTIVE: To determine what if any differences in presentation exist between men and women who present with acute intracerebral hemorrhage (ICH) to the emergency department (ED). METHODS: This was an IRB approved prospective cohort study of ED patients presenting with acute intracerebral hemorrhage. Statistical analyses were performed in JMP 14.1. Non parametric methods were used for skewed variables. The study was conducted in a comprehensive stroke center. The independent variable was the ICH score, and the dependent variable of interest was ultimate disposition (death or hospice vs. home or skilled nursing facility). RESULTS: The cohort consisted of 129 patients (54 women and 75 men). The median age was 71 years (IQR 58-81). The baseline co-morbidities were similar between both men and women and whether or not they were independent in their activities of daily living prior to experiencing their ICH. The overall median ICH score for women was 2, IQR 1-4, and 1 for men, IQR 1-2 (P = 0.0369) . A higher ICH score was significantly associated with in-hospital death and or hospice status (P = .0095, 95% CI 0.6340 - 0.4825). Conversely, a lower ICH score was significantly associated with being discharged home (P< 0.001, 95% CI -0.1694 to -0.0759). CONCLUSION: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage. A higher ICH score is significantly associated with the worse outcomes of death and/or hospice.

Every one-minute delay in EMS on-scene resuscitation after out-of-hospital pediatric cardiac arrest lowers ROSC by 5.

OBJECTIVE: To determine which aspects of prehospital care impact outcomes after pediatric cardiac arrest. METHODS: In this study, the authors examine 5 years of consecutive data from their county emergency medical system (EMS), to identify predictors of good outcome after pediatric cardiac arrest, including return of spontaneous circulation (ROSC), survival to hospital admission (HA) and survival to hospital discharge (HD). Three logistic regression models were performed using JMP 14.1 Pro for Windows, each with the following nine predictors: age, sex, ventilation method (endotracheal intubation vs. supraglottic airway), initial rhythm (pulseless electrical activity vs. asystole), epinephrine administration, bystander treatment prior to EMS arrival, time from collapse to EMS arrival, automatic external defibrillator (AED) placement, and whether the arrest was witnessed. Odds ratio confidence intervals were calculated using the Wald method, and corresponding p-values were obtained with the likelihood ratio χ2 test. RESULTS: From January 1, 2012 to December 31, 2016, there were 133 pediatric cardiac arrests, of which we had complete data on 109 patients for pediatric cardiac arrest. The median age was 8 months, with an IQR of 2.25-24 months, and a range of 0-108 months (0-9 years). There was return of spontaneous circulation (ROSC) in 20% of cases overall, with 16% making it to hospital admission, and 9% making it alive out of the hospital.The median time to EMS arrival for witnessed events was 10 min, with an interquartile range (IQR) of 6.5-16 min, and a range of 0-25 min. The median time to EMS arrival for unwitnessed events was 30 min, with an IQR of 19-62.5 min, and a range of 9-490 min.Predictors of ROSC included epinephrine administration (p = .00007), bystander treatment before EMS arrival (p = .0018), older age (p = .0025), shorter time to EMS arrival (p = .0048), and AED placement. Predictors of hospital admission included epinephrine NOT being administered (p = .0004), bystander treatment before EMS arrival (p = .0088), shorter time to EMS arrival (p = .0141), and AED placement (p = .0062). The only significant predictor of survival to hospital discharge alive that was identified was shorter time to EMS arrival (p = .0014), as there was insufficient data for many of the predictor variables in this analysis. CONCLUSION: Shorter time to EMS arrival from time of arrest, any bystander treatment prior to EMS arrival, and AED placement resulted in significantly higher rates of return of spontaneous circulation. Epinephrine administration significantly improved ROSC, but had the opposite effect on HA. Only shorter time to EMS arrival from time of arrest was significantly associated with survival to hospital discharge. Each additional minute for the EMS to arrive resulted in 5% decreased odds of ROSC and hospital admission, and 12% decreased odds of surviving to hospital discharge.

Real-World Field Performance of the Los Angeles Motor Scale as a Large Vessel Occlusion Screen: A Prospective Muticentre Study.

BACKGROUND: The Los Angeles Motor Scale (LAMS) is a 3-item, 0-to-5-point motor stroke-deficit scale derived from the Los Angeles Prehospital Stroke Screen. We assessed the predictive validity (for interventions performed and discharge disposition) of the LAMS performed in the field by paramedics in a geographic region of over 5,200 km2, covering both rural and urban areas. METHODS: We analyzed data gathered from Phase I of the LIT-PASS study (Large Vessel Occlusion Identification Through Prehospital Administration of Stroke Scales) which included all patients with suspected acute cerebrovascular disease, as assessed by the Balance, Eyes, Face, Arm, Speech, Terrible Headache/Time to Call 911 (BE-FAST) test. RESULTS: Among 1,906 patients with median age 72 years (interquartile range [IQR] 60-81), 53% were female with a median on-scene time of 15 min (IQR 12-19). C statistics for the interventions of mechanical thrombectomy, alteplase administration, computed tomography angiography, and perfusion imaging were 0.681, 0.643, and 0.680, respectively. The cut point for predicting these 3 interventions was confirmed to be LAMS ≥ 4. LAMS ≥ 4 had sensitivity 0.730 (0.661-0.790) and specificity 0.570 (0.539-0.601) for mechanical intervention (endovascular thrombectomy, coiling, or clipping) and relative risk of 2.98 (2.19-4.07) for in-hospital death. CONCLUSIONS: This real-world field study validates the LAMS as an effective tool for prehospital assessment of suspected strokes in determining transport decisions, with predictive validity for interventions performed.

Delta Lactate (Three-hour Lactate Minus Initial Lactate) Prediction of In-hospital Death in Sepsis Patients.

This study examines the relationship between serial serum lactate levels and in-hospital mortality in an adult cohort of emergency department patients with severe sepsis or septic shock. Of the 164 patients in the cohort, 130 also got three-hour lactate in addition to the initial one. The median initial lactate was 3.01 (interquartile range [IQR]: 1.71-4.62). The median repeat lactate was 2.58 (IQR: 1.4-3.9). The in-hospital death rate was 23% for men and 29% for women. The delta lactate was significantly higher in women (P=0.0070), driven by a lower initial lactate (P=0.0277). In a multivariate regression model controlled for age and gender, a statistically significant correlation was noted between an increase in the delta lactate and in-hospital death (P=0.0323; R2=11.3%). The results of this single-center study suggest that an increase in serum lactic acid is significantly associated with higher in-hospital death.

Serum Procalcitonin Level Is Associated with Positive Blood Cultures, In-hospital Mortality, and Septic Shock in Emergency Department Sepsis Patients.

This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

Large Vessel Occlusion Identification Through Prehospital Administration of Stroke Scales: A County-wide Emergency Medical Services Prospective Research Protocol.

There is yet insufficient research on prehospital stroke scales, especially for identifying large vessel occlusions and severe strokes. When multiple stroke centers are available, determining which patients should go directly to a comprehensive stroke center (CSC) is critical. Delay in care transporting to a hospital not capable of treating hemorrhagic strokes and large vessel occlusions (LVOs) can be devastating. The failure rate for tissue plasminogen activator (tPA), a clot-busting drug commonly used to treat ischemic stroke that can be administered at primary stroke centers, is up to 90% for large vessel occlusions (LVOs). However, these patients can benefit from mechanical intervention, performed only at CSCs. Hemorrhagic strokes often result from ruptured aneurysms, which can benefit from coiling and clipping, procedures also typically only available at CSCs. In order to analyze the effectiveness of certain prehospital stroke scales, our county's emergency medical services (EMS) system designed and implemented the LVO identification through prehospital administration of stroke scales (LIT-PASS), a prospective cohort study. Our study has three phases, each phase testing a certain combination of prehospital stroke scales. The protocol, including training for every paramedic, was started in 2015, and data collection began in 2016. In Phase 1, we tested the Los Angeles motor scale (LAMS) alone from January 2016 to November 2018. In Phase 2, we administered both the LAMS and the vision, aphasia, neglect (VAN) test from December 2018 to May 2019. Phase 3 began in June 2019 and uses the balance, eyes, face, arm, speech, terrible headache/time to call 911 (BE-FAST) test as a scale, allotting one point for each category. While the "time to call 911" aspect is not part of the scale, it is included in the name for mnemonic reasons. We chose these scales because of the symptoms they cover and due to their simplicity. Phase 1 assesses only motor symptoms, Phase 2 assesses motor and additional cortical symptoms, and Phase 3 evaluates a scale that combines both components and whose acronym is a useful mnemonic for paramedics. Each paramedic in our county's system was given a one-hour training session on the scales each year in Phase 1 and once prior to the beginning of Phase 2 and Phase 3. Paramedics were not allowed to respond to a stroke call unless they had completed the training. This is done to avoid bias in which patients are studied, ensuring that all stroke patients are subject to our county's stroke protocol. Data were de-identified and analyzed to evaluate the effectiveness of four things: in Phases 1 and 2, the LAMS alone; in Phase 2, the VAN test alone, as well as in combination with the LAMS; and in Phase 3, the effectiveness of the BE-FAST scale.

Globe Rupture and Protrusion of Intraocular Contents from Fall in Elderly Patient.

The authors present a case of globe rupture from a fall in an elderly patient. This patient had her intraocular contents protruding and experienced complete vision loss in her right eye. The emergency management and downstream surgical care is discussed, as well as the use of the Ocular Trauma Score to predict prognosis. Our patient had an Ocular Trauma Score of 1, considering right retinal detachment and perforating injury.

Diagnosing Appendicitis in Pregnancy Via Ultrasonography.

The authors present a case of acute appendicitis during a first trimester pregnancy. Appendicitis in pregnancy is especially dangerous because perforation of the appendix increases the likelihood of maternal and fetal morbidity significantly. For this reason, it is important to diagnose and treat suspected appendicitis in pregnancy as soon as possible. The patient was diagnosed with appendicitis via a transabdominal ultrasound. She was provided antibiotics and underwent a laparoscopic appendectomy and recovered without complications.

Gender Differences in Outcomes after Non-traumatic Intracerebral Hemorrhage.

Background Nontraumatic intracranial hemorrhages (ICH) are serious cerebrovascular events with high morbidity and mortality. They occur in about two million people a year worldwide. While ICH continues to be a focus of research in the medical community, there is little data on the differences in outcomes by gender. We aimed to further investigate these differences in our study. Methods This analysis involves a de-identified dataset of all adult patients who presented to one of our hospital system's emergency departments with ICHs as one of the top three discharge diagnoses. This study was considered exempt by our medical school's Institutional Review Board (IRB). Our hospital system comprises over 176 hospitals in the United States with over 8.6 million emergency department visits annually. Logistic regression analyses were performed using JMP 14.1. Outcome variables included the length of stay, mortality, and disposition. Results The cohort (n = 8069) comprised 68% Caucasians, 17% Blacks, 5% Asians, and 1% Hispanic. Forty-eight percent of patients were females with a median age of 71 years. Fifty-two percent of patients were males with a median age of 65 years. One-fifth of the cohort (20%) died while another fifth (21%) were discharged home. Thirteen percent joined hospice. Women were significantly more likely to die or join hospice (p <0.0001, OR 1.304, 95% CI: 1.183-1.440) even after controlling for age. Women also had a significantly shorter length of stay even when controlled for age (P = 0.0002, 95% CI: -1.58 to -0.489, R 2 = 1.5%) with a median of four days for men and three days for women. Conclusion The median age for women with nontraumatic ICH is older than men, which could explain their increased rates of mortality and discharge to hospice. However, even after controlling for age, women were significantly more likely to die or be discharged to hospice. Conversely, men and younger patients had a longer hospital stay and a higher likelihood of being discharged home.

Traumatic Multi-Finger Amputations After Trying to Rein in a Horse.

The authors present a case of traumatic, multiple partial-digit amputations caused by the patient entangling three of his fingers in the reins of a moving horse. The patient experienced amputation in fingers III-V on the dominant, right hand. The patient was stabilized and provided analgesia before referral to a surgical center for potential replantation. The emergency management of traumatic finger amputations is reviewed.

Electrical Cardioversion for Wide Complex Tachycardia.

We present a case of electrical cardioversion used to treat a hemodynamically unstable wide complex tachycardia (WCT). The patient returned to normal sinus rhythm after being cardioverted with 100 joules (J) on the first attempt. He was admitted to the hospital for cardiac evaluation and ultimately discharged home on flecainide and nebivolol after a negative cardiac workup.

Laparoscopic Adjustable Gastric Band Slippage Presenting as Chest Pain.

With the increasing popularity of bariatric procedures, complications are also more commonly seen. In this case, the authors discuss the case of a laparoscopic adjustable gastric band (lap band) that slipped from its correct position, diagnosed via plain radiographs. The patient was admitted for gastroenterology consultation and subsequently had her lap band fixed.

Preseptal and Postseptal Orbital Cellulitis of Odontogenic Origin.

The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.

Severe Hypothermia in the Sunshine State.

The authors present a case of accidental hypothermia in a region with a warm climate. The article includes a review of the stages of hypothermia as well as the management of hypothermia. Clinicians need to be vigilant for this condition even in places with warm weather.

Traumatic Corneal Abrasion.

Corneal abrasions can have potentially sight-threatening consequences if not accurately diagnosed and managed appropriately in the acute period. Simple corneal abrasions can be managed with antibiotic and tetanus prophylaxis, analgesia, and next-day follow up with ophthalmology. However, if there is any suspicion for penetrating eye injury, corneal ulcer, a sight-threatening infection such as bacterial keratitis, or ophthalmic zoster, an emergent referral is imperative. In this report, we present a case of classic corneal abrasion and discuss the acute management of this common problem.