Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Introduction: Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. Methods: A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Results: Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32 mmHg, mean heart rate was 81±16 bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90 mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Conclusion: Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Factors Predictive of Mortality among Geriatric Patients Sustaining Low-Energy Blunt Trauma.

Background: In geriatric trauma patients, higher mortality rate is observed compared to younger patients. A significant portion of trauma sustained by this age group comes from low-energy mechanisms (fall from standing or sitting). We sought to investigate the outcome of these patients and identify factors associated with mortality. Methods: A retrospective review of 1285 geriatric trauma patients who came to our level 1 trauma center for trauma activation (hospital alert to mobilize surgical trauma service, emergency department trauma team, nursing, and ancillary staff for highest level of critical care) after sustaining low-energy blunt trauma over a 1-year period. IRB approval was obtained, data collected included demographics, vital signs, laboratory data, injuries sustained, length of stay and outcomes. Patients were divided into three age categories: 65−74, 75−84 and >85. Comorbidities collected included a history of chronic renal failure, COPD, Hypertension and Myocardial Infarction. Results: 1285 geriatric patients (age > 65 years) presented to our level 1 trauma center for trauma activation with a low-energy blunt trauma during the study period; 34.8% of the patients were men, 20.5% had at least one comorbidity, and 89.6% were white. Median LOS was 5 days; 37 (2.9%) patients died. Age of 85 and over (OR 3.44 with 95% CI 1.01−11.7 and 2.85 with 95% CI 1.0−6.76, when compared to 65−74 and 75−84, respectively), injury severity score (ISS) (OR 1.08, 95% CI 1.02 to 1.15) and the presence of more than one comorbidity (OR 2.68, 95% CI 1.26 to 5.68) were independently predictive of death on multi-variable logistic regression analysis. Conclusion: Age more than 85 years, higher injury severity score and the presence of more than one comorbidity are independent predictors of mortality among geriatric patients presenting with low-energy blunt trauma.

Utility of ultrasound after a negative CT abdomen and pelvis in the emergency department.

PURPOSE: The purpose of this study is to assess the utility of an abdominal and/or pelvic ultrasound (US) performed within 24 h after a negative CT of the abdomen and pelvis (CTAP) in the emergency department (ED). The secondary endpoint is to assess whether there is a significant increase in length of stay (LOS) in the ED due to immediate US reimaging. METHOD: We reviewed the imaging reports of 335 patients over the course of 3 years in our ED who had an US within 24 h after a negative CTAP. We then assessed type of US and whether the US showed any acute findings. We also evaluated LOS in the ED. RESULTS: Out of 335 patients, there were only three US cases suspicious for acute surgical pathology (3/335 or 0.9%). On 30-day clinical follow-up, only one of the three cases was confirmed as cholecystitis on pathology. The most common non-surgical findings on US not initially reported on CTAP were ovarian cysts (29/83) and gallstones (9/83). Additionally, the LOS for patients who received both a CTAP and US was 119 min longer than patients who only received a CTAP. CONCLUSION: US abdomen and/or pelvis reimaging within 24 h following a negative CTAP is unlikely to change surgical management in the acute setting. US reimaging can still be useful in diagnosing non-surgical pathology, which could serve to explain the patient's pain. US reimaging after negative CTAP is associated with an average increase in the ED LOS.

Does Specialty Training and Practice Setting Affect Adherence to the Pediatric Emergency Care Applied Research Network Criteria for Pediatric Head Trauma?

OBJECTIVE: The goal was to determine the effects of specialty training and practice settings on the adherence to the Pediatric Emergency Care Applied Research Network (PECARN) criteria. METHODS: A retrospective study was conducted on a 2-campus hospital. Chart documentation was used to determine adherence to PECARN criteria. Inclusion criteria were any traumatic head injury within 24 hours in patients younger than 18 years over a 1-year period. Specialty training was subdivided into 3 groups: pediatric emergency medicine, emergency medicine (EM), and general pediatrics. The 2 hospital campuses are distinctly different practice settings, one being an academic practice setting, which is also a trauma center that has a dedicated pediatric emergency department, staffed by pediatric emergency medicine, EM, and general pediatrics physicians, and the second campus is a community practice and is staffed solely by EM physicians. Statistical analysis was performed using χ and Cochran-Mantel-Haenszel tests. All analyses were 2-sided, and P < 0.05 was considered statistically significant. RESULTS: A total of 709 pediatric patients with traumatic head injuries were analyzed. Overall adherence to PECARN criteria was 93%. No statistical difference was found between different specialty training on the academic campus. In addition, the rate of adherence among EM physicians at the academic and community settings was 94.8% versus 86.5%, respectively (P = 0.004). CONCLUSIONS: Practice setting had an effect on adherence to PECARN criteria in pediatric patients with acute traumatic head injury. The same determination on adherence was not demonstrated among physicians with different specialty trainings.

Does Initial Temperature in the Emergency Department Predict Outcomes in Patients Admitted for Sepsis?

BACKGROUND: Sepsis is a leading cause of morbidity and mortality in hospitalized patients. Prompt recognition and early treatment has been shown to improve mortality. Both low and high temperature are among the four elements of systemic inflammatory response required for the diagnosis of sepsis. We hypothesized that initial temperature has an effect on the identification, treatment, and outcomes of septic patients. OBJECTIVE: Our aim was to determine the prognostic and diagnostic utility of the initial recorded body temperature in patients presenting to the emergency department (ED) with sepsis. METHODS: This retrospective cohort study was conducted in the ED of a single facility during the study period of January 1, 2014 through December 31, 2014. Inclusion criteria were adult subjects 18 years of age and older who were admitted to the hospital from the ED with a diagnosis of sepsis. RESULTS: Hypothermia on presentation was associated with a longer time to antibiotics treatment of 338.6 min (p = 0.002), longer length of stay of 14.5 days (p < 0.001), higher rate of intensive care unit (ICU) admission of 32.7% (p = 0.003), and higher mortality rate of 30.8% (p < 0.001). CONCLUSIONS: In this study of adult patients diagnosed in the ED with sepsis, hypothermia correlated with increased time to initial antibiotics, length of stay, rate of ICU admission, and mortality. Therefore, hypothermia in the setting of sepsis requires early and aggressive intervention to prevent adverse outcomes and delays in care.

Effects of eliminating routine use of oral contrast for computed tomography of the abdomen and pelvis: A pilot study.

INTRODUCTION: Computed tomography (CT) of the abdomen and pelvis using only intravenous contrast has been shown to have a high degree of accuracy in evaluating abdominal pain. The aim of this study was to determine the effect on time to completion of study, time to radiologist read, and length of stay in the emergency department (ED) of implementing a protocol that stopped the routine use of oral contrast for CT of the abdomen and pelvis. METHODS: This was a single-center, retrospective cohort study. All patients ≥18 years of age who presented to the ED and required a CT of the abdomen and pelvis during the hours 0700-1500 were included. There were two one-month study periods, before and after implementing a protocol that specified oral contrast should only be used for CT scans of the abdomen and pelvis if body mass index <25 kg/m2 or age < 30 years, or if there was history of inflammatory bowel disease, gastrointestinal surgery, or suspected bowel malignancy. RESULTS: During the pre- and post-implementation periods, there were 93 and 83 patients, respectively, with mean times to CT completion of 158 min and 135 min, representing a reduction of 23 min (15%). The mean lengths of stay in the pre- and post-implementation periods were 365 min and 336 min, a decrease of 29 min (8%). CONCLUSION: A protocol without the routine use of oral contrast for CT of the abdomen and pelvis can result in improved time to completion and ED length of stay.

Do hemolyzed potassium specimens need to be repeated?

BACKGROUND: In the emergency department (ED), hyperkalemia in the presence of hemolysis is common. Elevated hemolyzed potassium levels are often repeated by emergency physicians to confirm pseudohyperkalemia and to exclude a life-threatening true hyperkalemia. OBJECTIVES: We hypothesize that in patients with a normal renal function, elevated hemolyzed potassium, and normal electrocardiogram (ECG), there may not be a need for further treatment or repeat testing and increased length of stay. METHODS: Data were prospectively enrolled patients presenting to the ED from July 2011 to February 2012. All adult subjects who had a hemolyzed potassium level ≥ 5.5 mEq/dL underwent a repeat potassium level and ECG. The incidence of true hyperkalemia in this population was measured. RESULTS: A total of 45 patients were enrolled. The overall median age was 52 years (range 25-83 years); 22 were female (49%). In patients with hyperkalemia on initial blood draw and glomerular filtration rate (GFR) ≥ 60 (n = 45), the negative predictive value was 97.8% (95% confidence interval [CI] 88.2-99.9%). When patients had hyperkalemia on initial blood draw, GFR ≥ 60, and a normal ECG (n = 42), the negative predictive value was 100% (95% CI 93.1-100%). CONCLUSIONS: In the setting of hemolysis, GFR ≥ 60 mL/min in conjunction with a normal ECG is a reliable predictor of pseudohyperkalemia and may eliminate the need for repeat testing. In patients with a normal GFR who are otherwise deemed safe for discharge, our results indicate there is no need for repeat testing.

Adult female with hematemesis-Dieulafoy lesion.

A 40-year-old healthy woman presented to the emergency department with a complaint of intermittent hematemesis, despite the absence of usual factors associated with upper gastrointestinal bleeding (ie, nonsteroidal anti-inflammatory drugs, alcoholism, etc). The patient was diagnosed with a Dieulafoy lesion. This is an uncommon finding, which clinicians must be familiar with and maintain in the differential diagnosis because the consequences of this disease process are grave. It is vital to properly diagnose this condition and be familiar with the treatment.

Sublingual capnometry for rapid determination of the severity of hemorrhagic shock.

BACKGROUND: Sublingual capnometry (SLCO2) is a rapid, minimally invasive bedside test of focal tissue perfusion. We hypothesized that SLCO2 could diagnose hemorrhagic shock and monitor adequacy of resuscitation. We compared the ability of SLCO2, serum lactate (LAC), and base deficit (BD) to predict outcome in hypotensive trauma patients. METHODS: Prospective, observational trial at two Level I trauma centers was performed. Inclusion criteria were blunt or penetrating trauma patients, age > or =16 years, with hypotension (systolic blood pressure < or =90 mm Hg). SLCO2, LAC, and BD were measured in each patient at admission, at the end of active hemorrhage, and at 6, 24, and 48 hours. Data are reported as means (+/-SD). RESULTS: A total of 86 patients were enrolled: mean age 35 (+/-17) years, 80% male, 51% blunt trauma, Injury Severity Score score 20 (+/-14). Twenty patients died. SLCO2 at admission was 52.4 (+/-13.3) in survivors versus 87.9 (+/-35.6) in nonsurvivors (p < 0.001). Receiver operating characteristic (ROC) curves showed that SLCO2, LAC, and BD were all good predictors of mortality. The area under each ROC curve was as follows: SLCO2 (0.82; 95% CI 0.70-0.96; p < 0.001), LAC (0.80; 95% CI 0.69-0.91; p < 0.001), BD (0.87; 95% CI 0.77-0.98; p < 0.001). There was no significant difference (p > 0.05) in the areas under the three curves. CONCLUSIONS: SLCO2 predicted survival in hypotensive trauma patients. It had equivalent diagnostic ability to LAC and BD. This rapid test may supplement standard, more invasive measures of hemorrhagic shock.