Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage.

INTRODUCTION: Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes. METHOD: We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home. RESULTS: We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BPSV) (31,[IQR 18-45) compared with those receiving 4 or less pMVIs (38[IQR 16-70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BPSV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home. CONCLUSIONS: In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.

Automated analysis of the 12-lead ECG in the emergency department: association between high-sensitivity cardiac troponin I and the cardiac electrical biomarker.

Timely detection of myocardial injury is essential for appropriate management of patients in emergency department (ED) evaluated for acute myocardial infarction. A novel electrocardiogram (ECG) metric, the Cardiac Electrical Biomarker (CEB), uses eigenvalue modeling of the 12-lead ECG and quantifies dipolar vs. multipolar forces. The goal of this project was to study association between the CEB and high-sensitivity troponin I (HsTnI). We conducted a retrospective study of patients, evaluated in the ED for acute myocardial infarction [n = 411; 57.6 ± 13.2 years; 186 (45%) men; 266 (64%) African-Americans]. Resting 12-lead ECG and HsTnI were measured at presentation and at 3, 6, and 9 hours after the initial measurement. The CEB was measured by the VectraplexECG System (VectraCor, Totowa, NJ). Patient-specific longitudinal analysis was performed to study association between the CEB with HsTnI changes over time. The CEB indicated myocardial injury in 116 (28.2%) study participants. HsTnI was significantly elevated during ED observation period in patients with myocardial injury, diagnosed by the CEB [median (interquartile range), 10.3 (5.2-31.4) vs. 6.3 (3.5-16.5) ng/L; P = 0.002]. In a mixed-effects linear regression adjusted for age, race, and sex, increasing HsTnI was associated with the CEB elevation [ß-coefficient, 0.071 (95% confidence interval, 0.008-0.134); P = 0.027]. In conclusion, in patients in ED evaluated for acute myocardial injury, increasing values of HsTnI were associated with increasing values of the CEB, suggesting that myocardial injury is the mechanism that underlines acute changes in the CEB.