False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series.

INTRODUCTION: The use of transcutaneous pacing (TCP) for unstable bradycardia has a class 2B recommendation from the American Heart Association. Prior studies have not adequately described the frequency or possible causes of treatment failure. EMS clinicians and leaders have reported false electrical capture as a potential cause. In this study, we aimed to describe the frequency of true electrical capture, documented verification of mechanical capture, and its association with systolic blood pressure (SBP) and survival. METHODS: This was a retrospective study of patients treated by an urban, hospital-based EMS network comprising two EMS agencies between March 2021 and March 2023. Inclusion criteria were adults with a heart rate of <60 bpm and attempted TCP. Variables included: initial electrocardiogram rhythm, SBP, current applied, neurological status at discharge, and diagnosis. The primary outcome was true electrical capture, defined as the presence of a visible wide QRS and T wave. This enabled calculation of false electrical capture. Additional outcomes included change in SBP and neurological status at discharge. RESULTS: 19 of the 23 (82.6%) patients who underwent TCP had false electrical capture despite all 23 having documented mechanical capture by palpated pulse. For patients with true electrical capture, the median change in SBP was +40 mmHg (IQR = 24.25, range= -12 to +49 mmHg). For patients with false electrical capture, the median change in SBP was -1 mmHg (IQR = 58.50, range= -90 to +23 mmHg). Median current for patients with true electrical capture was 95 mA (IQR = 13.75, range = 85-110) versus 70 mA (IQR = 30, range = 55-160) in those with false electrical capture. 16 (69.6%) had outcome data available. Patients with true electrical capture and outcome data (n = 2) survived to admission but only one survived to discharge with good functional capacity. Of 14 with false electrical capture and outcome data, 10 (71.4%) survived to admission; none survived to discharge with functional capacity. CONCLUSIONS: These findings suggest a high proportion of patients undergoing TCP are at risk of false electrical capture despite a recorded palpable pulse. While our analysis is limited to a single EMS network, these data raise concerns regarding the incidence of prehospital false electrical capture. Further research is warranted to calculate the incidence of false electrical capture and evaluate mitigation strategies.

Demographic and socioeconomic disparities in receipt of ophthalmology consultation for facial trauma.

OBJECTIVE: Functional outcomes following facial and ocular trauma are time-sensitive and require prompt evaluation to minimise long-term vision loss, yet few studies have systematically evaluated disparities in the management of these cases. This study investigates whether a patient's race/ethnicity, primary language, insurance status, gender or age affects receipt of ophthalmology consultation for facial trauma. METHODS AND ANALYSIS: This study was a retrospective cohort analysis of patients from the Elmhurst City Hospital Trauma Registry in Queens, New York who were seen for facial trauma including open globe injuries and orbital fractures between January 2014 and May 2016. RESULTS: Of the 264 patients included, 43% reported as Hispanic, 23% white, 11% Asian, 8% black and 15% other/unknown. After controlling for confounding variables by multivariable logistic regression, neither race/ethnicity, gender, nor primary language were significantly associated with the likelihood of receiving an ophthalmology consult. However, patients with private insurance had 2.57 times greater odds of receiving an ophthalmology consultation than those with Medicaid or state corrections insurance (95% CI 1.37 to 4.95). As age increased, the likelihood of receiving an ophthalmology consultation decreased (p=0.009); patients 60 years of age and older had one-third the odds of ophthalmology consultation as younger patients (OR 0.33; 95% CI 0.16 to 0.68). CONCLUSIONS: This study highlights that lack of ophthalmology consultation in patients with facial trauma is linked to age and underinsurance. Extra attention must be paid during primary assessments to ensure elderly patients and those with public insurance have equitable access to timely and appropriate care for facial trauma.

Outcomes in Critically Ill Patients With Traumatic Brain Injury: Ethnicity, Documentation, and Insurance Status.

OBJECTIVES: Disparities in traumatic brain injury outcomes for ethnic minorities and the uninsured have previously been demonstrated; however, outcomes in undocumented immigrants have not been examined. We wanted to determine whether ethnicity, insurance, and documentation status served as risk factors for disparities in traumatic brain injury outcomes between undocumented immigrants and documented residents. DESIGN: Retrospective study. SETTING: Patients diagnosed with traumatic brain injury admitted to the surgical/trauma ICU at a level 1 trauma center serving a large immigrant population in New York City from 2009 to 2016. PATIENTS: Four-hundred seventy-one traumatic brain injury patients requiring surgical/trauma ICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Undocumented immigrants constituted 29% of the population, were younger (39 vs 57 yr old, respectively; p < 0.0001), Hispanic (83%; p < 0.0001), and uninsured (87%; p < 0.0001). Falls resulted in the majority of traumatic brain injuries in the total population, however, undocumented immigrants were almost twice as likely to be assaulted (p = 0.0032). There was no difference in presence of midline shifts, Injury Severity Score, Glasgow Coma Score, hypotension, hypoxia, and pupillary reactions between undocumented immigrants and documented residents. Undocumented immigrants presented with significantly more effaced basilar cisterns (p = 0.0008). There was no difference in hospital care between undocumented immigrants and documented residents as determined by emergency department to surgical/trauma ICU transfer times (p = 0.967). Undocumented immigrants were more likely to be discharged home (53% vs 33%, respectively; p = 0.0009) and less likely to be sent to rehabilitation (25% vs 32%, respectively; p = 0.0009). After adjusting length of stay and mortality for covariates, undocumented immigrants had shorter length of stay (p < 0.05) and there was no difference in hospital mortality between undocumented immigrants and documented residents. CONCLUSIONS: Undocumented immigrants with traumatic brain injuries were more likely to be younger, have shorter length of stay, and experience similar mortality rates to documented residents. Social economic status may play a role in events prior to hospitalization and likely does in disposition outcomes.

Trauma care in a multiethnic population: effects of being undocumented.

BACKGROUND: Epidemiologic studies have shown that undocumented immigrants (UIs) display characteristics of having a low socioeconomic status and are primarily of ethnic minorities. These social determinants of health are known to be associated with diminished health care access and poor clinical outcomes. We therefore investigated the impact of documentation status on the clinical outcomes of patients with traumatic injuries. MATERIALS AND METHODS: We conducted a retrospective review of the trauma registry at our safety net institution for all adult patients who were admitted from 2010 to 2014. UIs were identified by the absence of a valid social security number within their medical records. Multivariate regression analysis was used to determine the impact of documentation status on in-hospital mortality, length of stay (LOS), and the odds of rehab placement. RESULTS: 4924 trauma patients met the study criteria, of which 1050 (21.3%) were UIs. There was no significant difference in mortality rates between the two populations. Multivariate regression analyses revealed a longer average LOS and a decreased likelihood for placement in an in-patient rehabilitation facility following hospitalization for UIs, even after accounting for insurance, age, injury severity, and other possible confounders known to affect these outcomes. CONCLUSIONS: There was no association between in-hospital mortality and documentation status; however, UIs had a longer average LOS and were less likely to be placed into rehab following their hospitalization. A longer LOS and a decreased likelihood for rehabilitation placement suggest that disparities in trauma care exist for UIs, putting them at risk for worse clinical and functional outcomes.