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.

Spontaneous Resolution of Tension Pneumocephalus Following Blunt Head Trauma.

The authors present a case of tension pneumocephalus that occurred secondary to closed head injury and review the etiology and management of this relatively rare entity. This case was managed without invasive neurosurgical intervention, also somewhat rare for this condition.

Outcomes following clonidine ingestions in children: an analysis of poison control center data.

BACKGROUND: This paper sought to characterize pediatric clonidine ingestions, report trends in incidence, and evaluate outcomes using the Florida Poison Center's data over a period of 15 years, from 2002 to 2016. RESULTS: There were 3444 total exposures. Forty percent of the cohort was female. The median age was 5 years. The age distribution changed over time to a higher proportion of teenagers exposed (p < 0.0001). From 2002 to 2016, exposures increased from 182 to 378 with a rise in incidence from 4.8 to 9.1 per 100,000 children. Acute on chronic exposures increased from 29.3% to 42.2% (p < 0.0001). Female intentional ingestions increased from 52 to 70% (p < 0.0001). Twenty-four percent were managed at home, 34% were discharged from the emergency department, 8% were admitted to the floor, and 25% were admitted to the intensive care unit (ICU). Major medical outcomes were associated with older age (p = 0.0043, 95% CI 0.0015 to 0.0080) and higher clonidine dose (p < 0.0001, 95% CI 0.0347 to 0.0600). Older children were more likely to ingest a larger dose of clonidine (p < 0.001, 95% CI 0.0531 to 0.0734), while younger children were more likely to be admitted to the ICU (p < 0.001, 95% CI - 0.0092 to - 0.0033). Males were more likely to have acute on chronic ingestions (p < 0.001, 95% CI - 0.1639 to - 0.0982); females were significantly more likely to be admitted to the ICU (p < 0.0001, 95% CI 0.0380 to 0.0969). CONCLUSIONS: Our analysis shows an increase in the incidence in pediatric clonidine exposures over time despite adjustment for population growth.

Transthoracic Echocardiographic Findings of Stanford Type A Aortic Dissection: A Case Report.

Aortic dissection is a well-known, but relatively uncommon diagnosis in the emergency department (ED). With a mortality rate as high as 30 percent, it is important to be able to diagnose quickly and accurately. Definitive diagnosis with imaging studies such as computed tomography angiogram (CTA) can be expensive and time-consuming and may not always be available in the community. Herein, we discuss a case of a 59-year-old man presenting with severe chest pain, hypotension, and bradycardia who was diagnosed with aortic dissection first by bedside ultrasound. This expedited the CTA and a cardiothoracic surgery consult, leading to a successful emergent aortic repair.

Sepsis Cards and Facts: A Simple Way to Increase Sepsis Bundle Compliance.

Objective The objective of this study was to improve sepsis bundle compliance via an educational intervention in our emergency department (ED). Methods This was a before and after study. Historical data on sepsis bundle compliance was obtained from our quality officer. Data were collected for 30 consecutive days to compare sepsis bundle compliance rates before and after the intervention. Descriptive statistics were compiled, and the z-test for proportions was used to calculate statistical significance. The intervention was two-fold: 1) a bright yellow card with sepsis criteria listed was posted on all ED workstation computers and 2) there was a daily email blast for one month with "sepsis facts." These email blasts were short pearls that highlighted the importance of recognizing and treating sepsis. Results The sepsis bundle compliance rates in the month prior to the intervention was 38%. In the month during the targeted intervention, the compliance rate increased to 56%. There was a statistically significant increase in bundle compliance rates during the intervention (p=0.0399). We also administered a survey to the ED attendings and residents following the completion of the study to assess whether they perceived that our intervention was helping them increase compliance with ordering the sepsis bundle. The response rate was 94%. To the question "Did you feel the sepsis cards placed on the workstations make you more likely to consider sepsis earlier in patients under your care in the emergency department?" 70% answered agree or strongly agree. To the question "Were you more likely to order the sepsis bundle after receiving the daily "Sepsis Facts"?" 29% were neutral while 59% answered agree or strongly agree. Finally, to the question "Did you feel the sepsis cards and "sepsis facts" help you improve the care of Septic patients in the emergency department?" 76% answered agree or strongly agree. Conclusion Sepsis criteria reminders and email blasts highlighting the importance of treating and recognizing sepsis can improve compliance with sepsis bundle ordering within the emergency department.

Mucinous Cystadenoma Causing Abdominal Distension: A Case Report.

Mucinous cystadenomas are a common benign neoplasm of the ovaries that can grow much larger than other adnexal masses. We report a case of a 28-year-old female who presented with one month of increasing abdominal distension and upper abdominal pain; she was found to have a 30-centimeter (cm) adnexal mass. Pathology showed a benign mucinous cystadenoma with no evidence of malignancy. The authors discuss the initial evaluation and management of adnexal masses in general, as the variety of etiologies and severity can make this a difficult task. The characteristics of different adnexal masses and the indications for gynecologic consultation and surgery are also discussed.

Parental Language and Return Visits to the Emergency Department After Discharge.

OBJECTIVE: Return visits to the emergency department (ED) are used as a marker of quality of care. Limited English proficiency, along with other demographic and disease-specific factors, has been associated with increased risk of return visit, but the relationship between language, short-term return visits, and overall ED use has not been well characterized. METHODS: This is a planned secondary analysis of a prospective cohort examining the ED discharge process for English- or Spanish-speaking parents of children aged 2 months to 2 years with fever and/or respiratory illness. At 1 year after the index visit, a standardized chart review was performed. The primary outcome was the number of ED visits within 72 hours of the index visit. Multivariable logistic regression was used to examine the relative importance of predictor variables and adjust for confounders. RESULTS: There were 202 parents eligible for inclusion, of whom 23% were Spanish speaking. In addition, 6.9% of the sample had a return visit within 72 hours. After adjustment for confounders, Spanish language was associated with return visit within 72 hours (odds ratio, 3.49; 95% confidence interval, 1.02-11.90) but decreased risk of a second visit within the year (odds ratio, 0.28; 95% confidence interval, 0.12-0.66). CONCLUSION: Spanish-speaking parents are at an increased risk of 72-hour return ED visit but do not seem to be at increased risk of ED use during the year after their ED visit.