Preparing for the Second Surge: Preventing Posttraumatic Stress Disorder and Building Resilience for Health Care Workers in the Face of COVID-19.

The global community needs to be aware of the potential psychosocial consequences that may be experienced by health care workers who are actively managing patients with coronavirus disease (COVID-19). These health care workers are at increased risk for experiencing mood and trauma-related disorders, including posttraumatic stress disorder (PTSD). In this concept article, strategies are recommended for individual health care workers and hospital leadership to aid in mitigating the risk of PTSD, as well as to build resilience in light of a potential second surge of COVID-19.

Evaluation of Bedside Sonographic Measurement of Optic Nerve Sheath Diameter for Assessment of Raised Intracranial Pressure in Adult Head Trauma Patients.

AIM: The aim was to evaluate the use of bedside sonographic measurement of the optic nerve sheath diameter (ONSD) in the assessment of elevated intracranial pressure in patients with head injury coming to the emergency department (ED). METHODS: A prospective study of ED patients presenting with a history of acute head injury, an ocular ultrasound was performed for ONSD measurement, followed by a computed tomography (CT) of the brain. Three measurements were taken for each eye, then, the mean binocular ONSD measurement for each patient was obtained to ensure accuracy. A mean bipolar ONSD >5 mm was considered abnormal. RESULTS: A total of 175 patients were considered for the study. Of 175 patients, only 56 (32%) had intracranial pathology detected on CT brain with mean ONSD of 5.7 mm (standard deviation [SD]: 0.59). The mean ONSD for 119 (68%) patients, who had normal CT brain, was 4.5 mm (SD: 0.42). The mean ONSD measured for the right eye was 4.86 mm with SD 0.88, and the mean ONSD for the left eye was 4.90 mm with SD 0.85. When comparing ONSD measurement with CT findings of raised intracranial pressure, the ONSD sensitivity was 87.5% (95% confidence interval [CI]: 85%-96%) and specificity was 94.1% (95% CI: 85%-96%), with a positive predictive value of 87.5% and a negative predictive value of 94.1%. The area under the receiver operator characteristic curve obtained was 0.90 (95% CI: 0.85-0.96). CONCLUSION: The study has shown a bedside measurement of ONSD through sonography as an efficient tool to assess elevations in intracranial pressure in head injury patients.

Practical Solutions for Healthcare Worker Protection During the COVID-19 Pandemic Response in the Ambulatory, Emergency, and Inpatient Settings.

OBJECTIVE: Protecting healthcare workers is an essential component of a successful response to the COVID-19 pandemic. The resource intensive nature of infectious disease protection, budgetary constraints, and global shortages of personal protective equipment (PPE) make this a daunting task. Practical, easily implemented strategies for healthcare workers (HCW) protection are needed. METHODS: We cross-reference the "Systems, Space, Staff, and Stuff" paradigm from disaster management and the "Hierarchy of Controls" approach to infection prevention from the Center for Disease Control and Prevention (CDC) to generate a narrative overview of worker protection strategies relevant to COVID-19. RESULTS: Alternative types of PPE, management of hazards, and reorganizing how people work can optimize HCWs protection. CONCLUSIONS: A comprehensive PPE strategy can utilize the "systems, space, staff, stuff" paradigm of disaster management to identify new or underutilized solutions to HCWs protection.

Validation of Predicting Hyperglycemic Crisis Death Score: A Risk Stratification Tool for Appropriate Disposition of Hyperglycemic Crisis Patients from the Emergency Department.

CONTEXT: Predicting hyperglycemic crisis death (PHD) score is a simple, rapid tool with six independent mortality predictors to calculate 30-day mortality and appropriately dispose patients to Intensive Care Unit (ICU) or ward. AIMS: This study aimed at validating the efficiency of PHD score as a decision rule for prognosticating 30-day mortality and classifying hyperglycemic crisis patients for appropriate disposition from the emergency department (ED). MATERIALS AND METHODS: This is a prospective, observational study done in the ED of a teaching hospital over 14 months. All patients aged >18 years and who met the criteria of hyperglycemic crisis were enrolled. Thirty-day mortality of six independent predictors was the primary end point. Using PHD, risk scores were calculated and patients were disposed as per physician's clinical judgment. Finally, the treating physician's decision and PHD score disposition were compared and the efficiency of PHD in predicting 30-day mortality was analyzed. Multiple logistic regression models were used for analysis. Receiver operating characteristic curve was drawn, and area under the curve along with sensitivity, specificity, positive predictive value, and negative predictive value was analyzed. P < 0.05 was considered statistically significant. RESULTS: A total of 133 patients were included. On applying PHD score, 69, 39, and 25 patients were in the low-, intermediate-, and high-risk groups, respectively, with a mortality rate of 5.8%, 20.5%, and 56%, respectively. On comparing physician disposition with PHD score, an increasing mortality was noticed in ICU, and PHD showed equal weight in risk stratification and appropriate disposition of patients. CONCLUSION: In adult patients with hyperglycemic crisis, PHD score is validated as a straightforward, prompt tool for predicting 30-day mortality and aids in disposition. The mortality rate in the PHD score Model II was similar to the physician's clinical decision.

Validation of the Cincinnati Prehospital Stroke Scale.

BACKGROUND: Early recognition of Stroke is one of the key concepts in the "Chain of Survival" as described by the American Heart Association/American Stroke Association Stroke guidelines. The most commonly used tools for prehospital assessment of stroke are "The Cincinnati Prehospital Stroke Scale," (CPSS) the "Face, Arm, Speech Test," and "The Los Angeles Prehospital Stroke Screen." The former two are used to identify stroke using physical findings while the latter is used to rule out other causes of altered consciousness. AIM: The aim of this study is to validate the CPSS in the prehospital setting by correlating with computed tomography scan findings. (1) To determine if these scores can be implemented in the Indian prehospital setting. (2) To determine if it is feasible for new emergency departments (EDs) to use these protocols for early detection of stroke. METHODOLOGY: A prospective, observational study from December, 2015 to March, 2016. Patients with suspected stroke were enrolled. Data were collected prehospital in patients that arrived to the ED in an ambulance. Sensitivity, specificity, positive predictive value, and negative predictive value of the score were calculated using standard formulae. RESULTS: CPSS showed good sensitivity of 81% (confidence interval [CI] - 68.5%-97%) when combined and a positive predictive value (PPV) of 100% (CI: 91.9%-100%). Individually, they showed a sensitivity of 75.8%, 79%, and 74.1%, respectively, with a PPV of 100% and specificity of 95%-100%. CONCLUSION: As a prehospital screening tool, CPSS can be extremely useful as any diagnosis is only provisional until confirmed by an appropriate investigation in a hospital.

Disaster Education: A Survey Study to Analyze Disaster Medicine Training in Emergency Medicine Residency Programs in the United States.

BACKGROUND: The increase in natural and man-made disasters occurring worldwide places Emergency Medicine (EM) physicians at the forefront of responding to these crises. Despite the growing interest in Disaster Medicine, it is unclear if resident training has been able to include these educational goals. Hypothesis This study surveys EM residencies in the United States to assess the level of education in Disaster Medicine, to identify competencies least and most addressed, and to highlight effective educational models already in place. METHODS: The authors distributed an online survey of multiple-choice and free-response questions to EM residency Program Directors in the United States between February 7 and September 24, 2014. Questions assessed residency background and details on specific Disaster Medicine competencies addressed during training. RESULTS: Out of 183 programs, 75 (41%) responded to the survey and completed all required questions. Almost all programs reported having some level of Disaster Medicine training in their residency. The most common Disaster Medicine educational competencies taught were patient triage and decontamination. The least commonly taught competencies were volunteer management, working with response teams, and special needs populations. The most commonly identified methods to teach Disaster Medicine were drills and lectures/seminars. CONCLUSION: There are a variety of educational tools used to teach Disaster Medicine in EM residencies today, with a larger focus on the use of lectures and hospital drills. There is no indication of a uniform educational approach across all residencies. The results of this survey demonstrate an opportunity for the creation of a standardized model for resident education in Disaster Medicine. Sarin RR , Cattamanchi S , Alqahtani A , Aljohani M , Keim M , Ciottone GR . Disaster education: a survey study to analyze disaster medicine training in emergency medicine residency programs in the United States. Prehosp Disaster Med. 2017;32(4):368-373.

Transfusion practices in trauma.

Resuscitation of a severely traumatised patient with the administration of crystalloids, or colloids along with blood products is a common transfusion practice in trauma patients. The determination of this review article is to update on current transfusion practices in trauma. A search of PubMed, Google Scholar, and bibliographies of published studies were conducted using a combination of key-words. Recent articles addressing the transfusion practises in trauma from 2000 to 2014 were identified and reviewed. Trauma induced consumption and dilution of clotting factors, acidosis and hypothermia in a severely injured patient commonly causes trauma-induced coagulopathy. Early infusion of blood products and early control of bleeding decreases trauma-induced coagulopathy. Hypothermia and dilutional coagulopathy are associated with infusion of large volumes of crystalloids. Hence, the predominant focus is on damage control resuscitation, which is a combination of permissive hypotension, haemorrhage control and haemostatic resuscitation. Massive transfusion protocols improve survival in severely injured patients. Early recognition that the patient will need massive blood transfusion will limit the use of crystalloids. Initially during resuscitation, fresh frozen plasma, packed red blood cells (PRBCs) and platelets should be transfused in the ratio of 1:1:1 in severely injured patients. Fresh whole blood can be an alternative in patients who need a transfusion of 1:1:1 thawed plasma, PRBCs and platelets. Close monitoring of bleeding and point of care coagulation tests are employed, to allow goal-directed plasma, PRBCs and platelets transfusions, in order to decrease the risk of transfusion-related acute lung injury.