Comparison of in-hospital and out-of-hospital cardiac arrest of trauma patients in Qatar.

BACKGROUND: Cardiac arrests in admitted hospital patients with trauma have not been described in the literature. We defined "in-hospital cardiac arrest of a trauma" (IHCAT) patient as "cessation of circulatory activity in a trauma patient confirmed by the absence of signs of circulation or abnormal cardiac arrest rhythm inside a hospital setting, which was not cardiac re-arrest." This study aimed to compare epidemiology, clinical presentation, and outcomes between in- and out-of-hospital arrest resuscitations in trauma patients in Qatar. It was conducted as a retrospective cohort study including IHCAT and out-of-hospital trauma cardiac arrest (OHTCA) patients from January 2010 to December 2015 utilizing data from the national trauma registry, the out-of-hospital cardiac arrest registry, and the national ambulance service database. RESULTS: There were 716 traumatic cardiac arrest patients in Qatar from 2010 to 2015. A total of 410 OHTCA and 199 IHCAT patients were included for analysis. The mean annual crude incidence of IHCAT was 2.0 per 100,000 population compared to 4.0 per 100,000 population for OHTCA. The univariate comparative analysis between IHCAT and OHTCA patients showed a significant difference between ethnicities (p=0.04). With the exception of head injury, IHCAT had a significantly higher proportion of localization of injuries to anatomical regions compared to OHTCA; spinal injury (OR 3.5, 95% CI 1.5-8.3, p<0.004); chest injury (OR 2.62, 95% CI 1.62-4.19, p<0.00), and abdominal injury (OR 2.0, 95% CI 1.0-3.8, p<0.037). IHCAT patients had significantly higher hypovolemia (OR 1.66, 95% CI 1.18-2.35, p=0.004), higher mean Glasgow Coma Scale (GCS) score (OR 1.4, 95% CI 1.3-1.6, p<0.00), and a greater proportion of initial shockable rhythm (OR 3.51, 95% CI 1.6-7.7, p=0.002) and cardiac re-arrest (OR 6.0, 95% CI 3.3-10.8, p=<0.00) compared to OHTCA patients. Survival to hospital discharge was greater for IHCAT patients compared to OHTCA patients (OR 6.3, 95% CI 1.3-31.2, p=0.005). Multivariable analysis for comparison after adjustment for age and gender showed that IHCAT was associated with higher odds of spinal injury, abdominal injury, higher pre-hospital GCS, higher occurrence of cardiac re-arrest, and better survival than for OHTCA patients. IHCAT patients had a greater proportion of anatomically localized injuries indicating solitary injuries compared to greater polytrauma in OHTCA. In contrast, OHTCA patients had a higher proportion of diffuse blunt non-localizable polytrauma injuries that were severe enough to cause immediate or earlier onset of cardiac arrest. CONCLUSION: In traumatic cardiac arrest patients, IHCAT was less common than OHTCA and might be related to a greater proportion of solitary localized anatomical blunt injuries (head/abdomen/chest/spine). In contrast, OHTCA patients were associated with diffuse blunt non-localizable polytrauma injuries with increased severity leading to immediate cardiac arrest. IHCAT was associated with a higher mean GCS score and a higher rate of initial shockable rhythm and cardiac re-arrest, and improved survival rates.

Urinary Diversion and Metabolic Acidosis: A Case Report.

Urinary diversion, a surgical technique to redirect urine usually after cystectomy, and its complications are potential challenges to physicians and early recognition decreases mortality and morbidity. A 45-year-old male with a history of type 2 diabetes mellitus and hypertension for over three years underwent urinary diversion as a treatment for invasive bladder cancer and was discharged ambulatory with an indwelling Foleys catheter. The patient returned to the emergency room with a primary complaint of hematuria. The patient was noted to be frail-looking, dehydrated and tachycardic. Laboratory results yielded an acute kidney injury reflected by the elevated creatinine, hyperkalemia and a venous blood gas demonstrating a hyperchloremic metabolic acidosis. The patient had bilateral distended renal calyces by ultrasound and irrigation of bladder through a three-way Foley showed to have large thick clots. The patient was admitted under the surgical intensive care unit after involving appropriate sub-specialties. The patient was started on sodium bicarbonate infusion, broad-spectrum antibiotics and a urinary catheter in place to monitor urine output. The patient's acidosis steadily improved with correction of his laboratory parameters, transferred out of ICU and the remaining stay in the medical ward was uneventful. The purpose of this case report is to help demonstrate the association between urinary diversion and the type of acidosis that subsequently develops in relation to this surgical procedure.

Acute Spinal Extradural Hematoma and Cord Compression: Case Report and a Literature Review.

A 50-year-old Asian male presented to the emergency department with sudden onset of bilateral lower limb weakness preceded by lower back pain, which developed after lifting a moderately heavyweight. As the pain increased in intensity, the patient was transferred by ambulance to the emergency department, and en-route lost complete motor (0/5 power and absent reflexes) and sensory control over his lower limbs. The patient's medical history was significant for diabetes mellitus, hypertension, chronic kidney disease, and coronary artery disease with percutaneous coronary intervention in 2018 and 2019. He was taking dual antiplatelets (aspirin and clopidogrel) along with other medications. Magnetic resonance imaging (MRI) showed findings suggestive of acute and extensive extradural hematoma extending from the foramen magnum to the level of the fifth lumbar vertebra (L5), exerting severe mass effect on the cord with evidence of edema, most severe at the level from 7th to 10th dorsal vertebrae (D7-D10) vertebral level. The clinical features and the radiological findings confirmed the diagnosis of acute cauda equina syndrome. This review is intended to promote awareness about a possible clinical correlation between the use of dual antiplatelet therapy as a risk factor of spinal hematomas and the cauda equina syndrome.

ABC/2 estimation in intracerebral hemorrhage: A comparison study between emergency radiologists and emergency physicians.

OBJECTIVES: We aimed to define levels of agreement (LOA) between emergency radiologists (RAD) and emergency medicine (EM) physicians for estimating bleed volume in intracranial hemorrhages (ICH) using ABC/2 formula. METHODS: A prospective study of a curated sample of head CT's were performed in an emergency department. Raters independently reviewed the scans. Perpendicular maximal dimensions (A and B) were measured on an axial CT image. The 'C' dimension was a product of slice thickness and number of slices with visible bleed. RESULTS: A hundred CT head examinations were included with a median age of 50 years (IQR 43 to 57). The median bleed volume was 11.2 mL (IQR 6.6-18.6) per the index radiologist estimations. The overall mean of differences between the RAD mean and the EM mean estimated bleed volume was 0.3 (95% CI -1.5 to +1.7) in milliliters. The percentage difference between EM and RAD expressed as median was 1.9% (IQR -13.4% to +14.1%). Compared to the index RAD the mean of differences for bleed volume [rater, mean (95% CI) in milliliters] were: second RAD, 1.19 (1.14 to 1.24); EM attending, 1.05 (0.98 to 1.13); senior fellow, 1.05 (1.00 to 1.10); junior fellow, 1.19 (1.06 to 1.33); senior resident, 1.29 (1.19 to 1.39); junior resident, 1.11 (1.03 to 1.20). The difference between EM versus radiologist, junior versus senior EM physician estimation of bleed size was clinically insignificant. CONCLUSIONS: Excellent level of agreement was found between emergency physicians and emergency radiologists for estimating ICH bleed volumes using ABC/2 formula.