Minimally invasive surgical treatment using ‘iliac pillar’ screw for isolated iliac wing fractures in geriatric patients: a new challenge

Abstract

Purpose

There have been no prior case series of isolated iliac wing fracture (IIWF) due to low-energy trauma in geriatric patients in the literature. The aim of this study was to describe the characteristics of IIWF in geriatric patients, and to present a case series of IIWF in geriatric patients who underwent our minimally invasive screw fixation technique named ‘iliac pillar screw fixation’.

Materials and methods

We retrospectively reviewed six geriatric patients over 65  years old who had isolated iliac wing fracture treated with minimally invasive screw fixation technique between January 2006 and April 2016.

Results

Six geriatric patients received iliac pillar screw fixation for acute IIWFs. The incidence of IIWFs was approximately 3.5% of geriatric patients with any pelvic bone fractures. The main fracture line exists in common; it extends from a point between the anterosuperior iliac spine and the anteroinferior iliac spine to a point located at the dorsal 1/3 of the iliac crest whether fracture was comminuted or not. Regarding the Koval walking ability, patients who underwent iliac pillar screw fixation technique tended to regain their pre-injury walking including one patient in a previously bedridden state. The visual analog scale score for pain at the last follow-up was quite satisfactory. Union was achieved in all patients at the last follow-up.

Conclusions

Geriatric patients can have a form of IIWF caused by low-energy trauma that is a type of fragility fracture of the pelvis. Because subsequent deterioration of their walking status followed by a long period of non-weight bearing in geriatric patients could be as threatening as the fracture itself, the treatment paradigm for IIWF due to low-energy trauma in geriatric patients should differ from that due to high-energy trauma in most patients. In these types of fractures, minimally invasive surgical management that includes iliac pillar screw fixation can lead to good outcomes.

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No correlation between lower extremity deep vein thrombosis and pulmonary embolism proportions in trauma: a systematic literature review

Abstract

Purpose

To assess the effect of surveillance on deep vein thrombosis (DVT) and pulmonary embolism (PE) rates, the efficacy of chemoprophylaxis and mechanical prophylaxis, and the relationship between DVT and PE.

Methods

A 23 year, systematic literature review was performed in PubMed. Twenty publications with > 13,000 patients were reviewed. Analyzed traits included: DVT surveillance utilization, the total number of patients included in each study, the number of patients developing DVT and/or PE, chemoprophylaxis and mechanical prophylaxis utilization. When event proportions from individual studies were combined, a weighted mean proportion was computed based on the size of each individual cohort. Combined event proportions were compared with other combined event proportions, according to differences in intervention. Inter-group event proportions were compared using Chi-Square or Fisher’s exact test, as appropriate.

Results

DVT rates increase with surveillance (10.7% vs. 2.5%, p < 0.001). PE rates were similar regardless of surveillance (p = 1.0). Chemoprophylaxis lowered both DVT rates (8.2% vs. 10.7%; p < 0.0001) and PE rates (1.2% vs. 1.9%; p = 0.0050). Mechanical prophylaxis did not decrease DVT rates (10.2% vs. 11.5%; p = 0.2980) or PE rates (1.7% vs. 1.6%; p = 1.0). In patients with neither chemoprophylaxis nor mechanical prophylaxis, DVT rate was 11.5%, PE was 1.6%. When chemoprophylaxis and/or mechanical prophylaxis were given, DVT rate was 8.6% (p < 0.0189) and PE was 1.3% (p = 0.4462). PE proportions were not decreased with mechanical prophylaxis or surveillance. DVT and PE rates were not associated (p = 0.7574).

Conclusions

The results suggest that PE is not associated with lower extremity DVT in adult trauma patients.

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EMS Specialist Projects Supervisor - GAAA

Make A Difference in your community by being a leader of our Emergency Medical Service Team! Galveston County Health District is seeking a new EMS Special Projects Supervisor! The right candidate will be responsible for successfully managing daily operational aspects of non-emergency medical transport and emergency medical services provided by the Galveston County Health District's Galveston Area Ambulance ...

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FT/PT Paramedic - Med-Star Paramedic Ambulance, Inc.

MED-Star Paramedic Ambulance, Inc. located in Brandon, South Dakota is currently hiring full and part time Paramedics. We are a family owned and operated company. We respond to 911 calls in the southeast area of Minnehaha county and provide interfacility transports from area hospitals. We offer flexible scheduling with 12 and 24 hour shifts available and minimal call time. Pay starting at $36,500-$42,000/year ...

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Wash. responders, civilians honored for saving life of retired fire chief

Retired Chehalis Fire Department Chief Bill Nacht went into cardiac arrest while waiting for a friend so they could go on a motorcycle trip

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EMCrit 236 – George Kovacs on EVLI Airway Incrementalization

Approach to steps of laryngoscopy/intubation

EMCrit Project by Scott Weingart.

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EMCrit 236 – George Kovacs on EVLI Airway Incrementalization

Approach to steps of laryngoscopy/intubation

EMCrit Project by Scott Weingart.

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External fixation of segmental tibial shaft fractures

Abstract

Purpose

Tibial shaft fractures are the most common type of large long-bone fractures. Segmental tibial shaft fractures are severe injuries and its treatment can be followed by a high incidence of complications, nonunion, delayed union, malunion, infection or compartment syndrome. The most common treatment strategy is intramedullary fixation. Results of the unilateral external fixation treatment for segmental tibial shaft injuries are presented in this paper.

Methods

Patients with segmental tibial shaft fractures, AO/OTA 42-C2 were treated as urgent cases by unilateral external fixation. Mitkovic-type external fixator was used in all of these fractures.

Results

There were 32 patients with segmental tibial shaft fractures (AO/OTA 42-C2), 20 males and 12 females, average age of 43.5 years. Average time of union was 5.9 (4.1–7.4) months for closed and 6.2 (5.1–7.9) months for open fractures. Average follow-up was 18 (26–60) months. Nine patients (28.12%) had open segmental tibial shaft fracture (2 Grade I, 2 Grade II, 1 Grade IIIA, 4 Grade IIIB). Union rate was 81.25% (26 cases). Nonunion rate was 18.75% (6 cases) and malunion 3.12% (1 case). Nonunion was higher in patients with open fractures (4). Compartment syndrome had been diagnosed in 6 cases (18.75%) with closed fracture and fasciotomy was performed when external fixator was applied. There were no deep infections. Pin tract infection was present in 7 cases (21.85%).

Conclusion

Treatment of segmented tibial shaft fractures can be followed by a number of complications. Unilateral external fixation with convergent orientation of pins provides three-dimensional stability of the fracture and good biomechanical conditions for fracture healing, with lower complications rate.

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Radial head arthroplasty for radial head fractures: a clinical and radiological comparison of monopolar and bipolar radial head arthroplasty at a mean follow-up of 6 years

Abstract

Purpose

The purpose of this study was to compare clinical and radiographic outcomes of bipolar and monopolar radial head arthroplasty in treatment of radial head fracture at a mean follow-up of 6 years.

Methods

A retrospective multicentre cohort study of 30 patients treated for unreconstructable radial head fractures. Patients were treated either with a cemented bipolar or an uncemented monopolar radial head arthroplasty. All patients included were evaluated with patient-rated outcome questionnaire, physical examination, and radiographic evaluation at a mean of 6 years (range, 2–12 years) postoperatively.

Results

There was no statistical difference in QuickDASH between the bipolar or monopolar groups. The majority of patients had no to little pain during rest. Neither flexion nor extension of the injured arm was significantly affected by the type of prosthesis. None of the patients in the bipolar group had any secondary surgery at the time of follow-up. In the monopolar group, four patients required removal of the arthroplasty. Signs of ulnohumeral degenerative changes were seen in the majority of patients in both groups (55% in the monopolar group, 92% in the bipolar group).

Conclusion

In this retrospective cohort study comparing a bipolar and a monopolar radial head arthroplasty for treatment of radial head fractures, we found comparable functional outcome but more revision procedures in the monopolar group at a mean follow-up of 6 years.

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Halloween: Is it the most dangerous day for kids?

Analysis of the 56 million ePCR records in the NEMSIS national dataset shows days with the most traumatic pediatric cardiac arrests in 2013 and 2014

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CoTCCC Chair Dr. Frank Butler Receives NAEMT’s Most Prestigious 2018 Rocco V. Morando Lifetime Achievement Award

CLINTON, Miss. — Captain Frank K. Butler, Jr., (USN ret), MD was presented with the 2018 Rocco V. Morando Lifetime Achievement Award, recognizing a lifetime of commitment, contributions and leadership to Emergency Medical Services (EMS). The award is NAEMT’s most prestigious and is generously sponsored by the National Registry of Emergency Medical Technicians (NREMT). The presentation...

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Halloween: Is it the most dangerous day for kids?

Analysis of the 56 million ePCR records in the NEMSIS national dataset shows days with the most traumatic pediatric cardiac arrests in 2013 and 2014

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EMS World Expo Quick Take: Assessing, treating and transporting patients with special needs

Be aware patients with special needs may have comorbidities, and their conditions fall on a spectrum

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EMS World Expo Quick Take: Active assailant preparation, response for EMS

20-60-90 minute rule underscores the importance of rapidly accessing trauma patients and transporting patients to definitive surgical care

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Paramedic Inpatient, (NICU/PICU - Flex) FT; 36 hours per week 5p-5a with weekend rotation - Children's Hospital & Medical Center

The inpaitent paramedic serves a clinical resource on inpateint units (critical care or med surg). Working to the full scope of their license, the paramedic will complete assessments, perform procedures, administer meds, and respond to emergencies in the assigned unit or division. The paramedic will interact with patients and famillies and be part of the pediatric and neonatal care team.

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IBCC chapter & cast: Anemia & transfusion targets

Most patients in the ICU will become anemic.  This chapter explores prevention, evaluation, and treatment of anemia in the ICU.  Causes of new-onset anemia in the ICU are distinct from the causes of anemia seen in the outpatient clinic, so the approach should be appropriately tailored to the critical care environment.   

EMCrit Project by Josh Farkas.

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IBCC chapter & cast: Anemia & transfusion targets

Most patients in the ICU will become anemic.  This chapter explores prevention, evaluation, and treatment of anemia in the ICU.  Causes of new-onset anemia in the ICU are distinct from the causes of anemia seen in the outpatient clinic, so the approach should be appropriately tailored to the critical care environment.   

EMCrit Project by Josh Farkas.

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Serum matrix metalloproteinase-9 is a valuable biomarker for identification of abdominal and thoracic aortic aneurysm: A case-control study

BMC Cardiovascular Disorders

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Effect and safety of antithrombotic therapies for secondary prevention after acute coronary syndrome: A network meta-analysis

Drug Design, Development and Therapy

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Factors associated with door-in to door-out delays among ST-segment elevation myocardial infarction (STEMI) patients transferred for primary percutaneous coronary intervention: A population-based cohort study in Ontario, Canada

BMC Cardiovascular Disorders

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Conditions and factors associated with spontaneous coronary artery dissection (from a national population-based cohort study)

American Journal of Cardiology

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A Historical Perspective of Lateral Canthotomy and Its Adoption as an Emergency Medicine Procedure

Publication date: Available online 30 October 2018

Source: The Journal of Emergency Medicine

Author(s): Michael V. Nguyen

Abstract

Background

The treatment of orbital compartment syndrome has a rich history rooted in surgery and emergency medicine. It is a rare but acute and vision-threatening condition that most commonly occurs secondary to facial trauma or as a postoperative complication, and was first recognized in 1950. Surgical techniques and medical management were developed and refined soon afterwards to eventually become the modern-day treatment, lateral canthotomy, and inferior cantholysis.

Objective

This article details the history of orbital compartment syndrome and the evolution of its treatment to the present day.

Discussion

Given the time-sensitive nature and acuity of orbital compartment syndrome, lateral canthotomy was adopted by emergency physicians who could perform it more quickly at the bedside.

Conclusions

Lateral canthotomy is a procedure adopted by emergency physicians from the surgical literature. The history of its adoption is a representative example of how emergency medicine evolves as a field.

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Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun

Publication date: Available online 30 October 2018

Source: The Journal of Emergency Medicine

Author(s): Ashley T. Panicker, Kenneth Nugent, Jennifer Mink, Jeffrey Glaser, Kevin Bradley, Franjo Siric, Jason T. Nomura

Abstract

Background

Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management.

Case Report

An elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair.

Why Should an Emergency Physician Be Aware of This?

With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.

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Skeletal Survey Yield in Young Children with Femur Fractures

Publication date: Available online 30 October 2018

Source: The Journal of Emergency Medicine

Author(s): Erika Moors Cornell, Elizabeth C. Powell

Abstract

Background

Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse.

Objective

We describe circumstances of injury, prevalence of suspicion for physical abuse, and use of imaging to identify additional occult fractures in young children with femur fractures.

Methods

We reviewed the medical records for children younger than 48 months old with femur fractures treated at a pediatric referral hospital (2011–2013). We abstracted age, ambulation, injury circumstances, bruising, head trauma, additional fractures, and determination of injury suspicious for abuse.

Results

In 22 of 127 (17%) children with femur fractures, there was strong suspicion for physical abuse. Infants ≤ 12 months old accounted for 19 of 22 (86%) of those with suspicious injuries. In 2 of 22 (9%) with suspected abuse, the child could walk independently. In 8 of 22 (36%) with suspicious injuries, an injury event was reported as directly witnessed versus 50 of 105 (48%) of the unintentional injuries. Six of 22 (27%) with suspicious injuries had bruises versus 11 of 105 (10%) with unintentional injuries (χ², p < 0.03). Four of 22 (18%) children with suspicious injuries had head trauma, versus 0 of 105 with unintentional injuries. Of the 8 with occult fractures identified on a skeletal survey (designated suspicious for abuse), all were ≤ 12 months old and none were walking independently.

Conclusions

Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.

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Emergency Physician–Administered Sedation for Pneumatic Reduction of Ileocolic Intussusception in Children: A Case Series

Publication date: Available online 30 October 2018

Source: The Journal of Emergency Medicine

Author(s): Itai Shavit, Danielle Shavit, Oren Feldman, Nir Samuel, Anat Ilivitzki, Daniel M. Cohen

Abstract

Background

Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.

Objective

The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI).

Methods

We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse.

Results

Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6–20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79–104 min), 10.5 min (IQR, 9–12 min), 21 min (IQR, 20–30 min), 25 min (IQR, 23–30 min), and 108 min (IQR, 82–161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation.

Conclusions

The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician–administered sedation for PRI.

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Assessing Risk of Future Suicidality in Emergency Department Patients

Academic Emergency Medicine, EarlyView.


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Massive Transfusion Protocols in Non-Trauma Patients: A Systematic Review and Meta-Analysis

Background Massive bleeding is a major cause of death both in trauma and non-trauma patients. In trauma patients, the implementation of massive transfusion protocols (MTP) led to improved outcomes. However, the majority of patients with massive bleeding are non-trauma patients. Objectives To assess if the implementation MTP in non-trauma patients with massive bleeding leads to improved survival. Data sources National Library of Medicine’s Medline database (PubMed). Study eligibility criteria Original research articles in English language investigating MTP in non-trauma patients. Participants Non-trauma patients with massive bleeding ≥ 18 years of age. Intervention Transfusion according to MTP versus off-protocol. Study appraisal and synthesis methods Systematic literature review using PubMed. Outcomes assessed were mortality and transfused blood products. Studies that compared mortality of MTP and non-MTP groups were included in meta-analysis using Mantel-Haenszel random effect models. Results A total of 252 abstracts were screened. Of these, 12 studies published 2007-2017 were found to be relevant to the topic, including 2,475 patients. All studies were retrospective and comprised different patient populations. Most frequent indications for massive transfusion were perioperative, obstetrical and gastrointestinal bleeding, as well as vascular emergencies. Four out of the five studies that compared the number of transfused blood products in MTP and non-MTP groups revealed no significant difference. Meta-analysis revealed no sigificant effect of MTP on the 24-hour mortality (OR 0.42, 95%CI 0.01-16.62, p=0.65) and a trend towards lower one-month mortality (OR 0.56, 95%CI 0.30-1.07, p=0.08). Limitations Heterogeneous patient populations and MTP in the studies included. Conclusions and implications of key findings There is limited evidence that the implementation of MTP may be associated with decreased mortality in non-trauma patients. However, patient characteristics, as well as the indication and definition of MTP were highly hetergenous in the available studies. Further prospective investigation into this topic is warranted. Study type Systematic review and meta-analysis Level of evidence Level III Author’s email addresses: Nora Sommer: nora_sommer@bluewin.ch Beat Schnüriger: beat.schnuriger@gmail.com Daniel Candinas: daniel.candinas@insel.ch Tobias Haltmeier: tobias.haltmeier@icloud.com Address of correspondence: Tobias Haltmeier, MD, FACS, Department of Visceral Surgery and Medicine, Division of Acute Care Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland, Phone: +41 31 632 59 00, Fax: +41 31 632 59 99. E-mail: tobias.haltmeier@icloud.com Disclosure: Nora Sommer, Beat Schnüriger, Daniel Candinas, and Tobias Haltmeier have no conflicts of interest or financial ties to disclose. © 2018 Lippincott Williams & Wilkins, Inc.

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An Introduction to Patient Reported Outcome Measures (PROMs) in Trauma

Increased survival rates from traumatic injury have resulted in more people living with disability and reduced quality of life. To understand how peoples’ quality of life is affected following a traumatic injury and the effects of that injury on their health and wellbeing, it is important to capture patients’ perspectives of their own health. Patient Reported Outcome Measures (PROMs) are questionnaires, completed by patients, which can be used to measure the symptom burden associated with trauma and its treatment, and impact on quality of life. PROMs have a wide variety of uses which are relevant to trauma. In a research setting, PROMs can be used to assess the effectiveness of treatment and burden of disease. In a clinical setting, PROMs have the potential to inform and guide patient-centred care and clinical decision making. Collected as part of trauma registries, PROMs can be used at an aggregate level to inform improvements and uphold the quality of trauma care. This literature review explores and summarise the key current and potential future uses of PROMs in trauma research, routine clinical practice and registries. Author’s email addresses: Grace M Turner,*: G.Turner.1@bham.ac.uk Anita Slade: A.L.Slade@bham.ac.uk Ameeta Retzer: A.Retzer@bham.ac.uk Christel McMullan: C.McMullan@bham.ac.uk Derek Kyte: D.G.Kyte@bham.ac.uk Antonio Belli: A.Belli@bham.ac.uk Melanie Calvert: M.Calvert@bham.ac.uk *Corresponding author: Grace M Turner | Murray Learning Centre, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK | +44 (0) 121 414 5463 | G.Turner.1@bham.ac.uk Conflicts of Interest and Source of Funding This review was funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. GT is funded by the NIHR PDR programme (PDF-2017-10-047) and the NIHR SRMRC. AR is funded by the NIHR SRMRC and employed on another project funded by Macmillan Cancer Support (grant: 5592105). DK is funded by the NIHR PDF programme (PDF-2016-09-009); Macmillan Cancer Support (grant: 5592105); NIHR Birmingham Biomedical Research Centre and the NIHR Surgical Reconstruction and Microbiology Research Centre. AS is funded by the NIHR SRMRC and is working on another project funded my Macmillan Cancer Support (grant ERN-17-0085). MC has received personal fees from Ferring and chairs the ISOQOL Best Practice for PROs in Trials Taskforce. © 2018 Lippincott Williams & Wilkins, Inc.

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Ketamine Infusion for Pain Control in Adult Patients with Multiple Rib Fractures: Results of a Randomized Control Trial

Introduction Rib fractures occur in up to 40% of trauma patients and are associated with increased mortality. Opiate-based pain regimens remain the cornerstone of rib fracture management; however, concerns around opioids have fostered interest in alternative analgesics. Ketamine is currently being used in lieu of opioids, but little evidence exists supporting its use within the trauma population. Methods A prospective, randomized, double-blind placebo-controlled trial of adult patients with ≥3 rib fractures admitted to a Level 1 trauma center was conducted. Exclusion criteria included age >64 years, GCS 15) demonstrated that LDK was associated with a significant reduction in OME utilization during the first 24-hours (35.7 vs. 68, p=0.03), 24-48 hours (64.2 vs 96, p=0.03), and overall (152.1 vs 198, p=0.048). No difference in other secondary outcomes or adverse events was noted. Conclusion LDK failed to decrease NPS or OME within the overall cohort, but a decrease in OME was observed among patients with an ISS >15. Confirmatory studies are necessary to determine if LDK is a useful adjunct among severely injured patients. Level of Evidence I Study Type Therapeutic Meeting Presentation: 77th Annual Meeting of the American Association for Surgery of Trauma, September 26-29, 2018 in San Diego, California Corresponding Author: Thomas W Carver MD, FACS, Societal Memberships: AAST and WTA, Medical College of Wisconsin, Department of Surgery, Division of Trauma and Acute Care Surgery, 8701 Watertown Plank Rd., Milwaukee, Wisconsin 53226 United States, Cell: 1 (847) 977-4896, Office: 1 (414) 955-1733, Fax: 1 (414) 955-0072 Conflict of Interest Statement: There are no conflicts of interests to report for any of the authors of this study. Source of Funding: This trial was funded through institutional grant funding (Research Affairs Committee Grant #3307034). Financial Disclosures: Drs. Carver and Kugler are paid consultant for InnoVital Systems Inc. The remaining authors have no financial disclosures. Disclosure: None of the authors have any financial and personal relationships with other people or organizations that could potentially and inappropriately influence their work and conclusions on this topic. © 2018 Lippincott Williams & Wilkins, Inc.

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Time Course and Outcomes Associated with Transient Versus Persistent Fibrinolytic Phenotypes After Injury: A Nested, Prospective, Multicenter Cohort Study

Background Temporal changes in fibrinolytic activity after injury and their impact on outcomes remain poorly defined. We conducted a prospective, multicenter cohort study to determine the incidence of fibrinolytic phenotypes after injury and the trajectories and associated outcomes of these phenotypes over time. Methods We included adults that arrived within six-hours of injury to three American, level-1 trauma centers. Clot lysis at 30-minutes (LY-30) was measured at presentation and 3-, 6-, 12-, 24-, 48-, 72-, 96-, and 120-hours. LY-30 was used to categorize patients into the following fibrinolytic phenotypes: fibrinolysis shutdown (SD, LY-30 ≤0.8%), physiologic fibrinolysis (PHYS, LY-30 >0.8% to

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Comparison of diagnostic accuracy FOR nonocclusive mesenteric ischaemia in models with biomarkers including intestinal fatty acid–binding protein in addition to clinical findings

Background Nonocclusive mesenteric ischemia (NOMI) is an acute and life-threatening gastrointestinal disorder, requiring rapid therapeutic intervention for ischemic bowel. However, its rapid detection remains challenging. This retrospective, observational study was aimed at comparing the diagnostic accuracy for NOMI in models of biomarkers, including intestinal fatty acid–binding protein (I-FABP), and clinical findings. Methods All consecutive patients who presented to the emergency department of the study hospital with suspected NOMI were prospectively enrolled. Receiver operating characteristic (ROC) analysis compared the diagnostic accuracy of I-FABP with traditional biomarkers (white blood cell count, C-reactive protein, lactate, creatine kinase, and D-dimer) alone and in combination with the baseline model established from clinical findings. Results Of 96 patients with suspected NOMI, 25 (26.0%) were clinically diagnosed with NOMI. In-hospital mortality was higher in patients with NOMI than those with other conditions (56.0% vs. 4.2%, P

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Authors' reply

No abstract available

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Battlefield pain management: A view of 17 years in Israel Defense Forces

No abstract available

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TRAUMA SURGEON PERFORMANCE OF APPENDECTOMY IN 5-10 YEAR-OLD CHILDREN IS SAFE AND DECREASES LENGTH OF HOSPITAL STAY

No abstract available

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Prediction of Traumatic Carotid-Cavernous Sinus Fistula via Non-Contrast CT by Fracture Pattern and Abnormality of Venous System

No abstract available

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In Reply

No abstract available

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Response to Letter to the Editor

No abstract available

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Reply to Laparoscopy in a Combat Theater of Operations

No abstract available

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Response to: Chemoprophylaxis for VTE Prevention in Spine Surgery Patients

No abstract available

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In Response to the Letter to the Editor: Beta Blockers Therapy in Traumatic Brain Injury Is It The Time to Disclose the Brain-Cardiac Interactions?

No abstract available

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Response to Letter to the Editor by Dr. Magnone (JT-D-18-08024)

No abstract available

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Response to the Letter to the editor by Drs Isci and Ritter: "Clinical features of 27 shark attack cases on La Réunion island."

No abstract available

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Precious Cargo: Modulation of the Mesenteric Lymph Exosome Payload after Hemorrhagic Shock

Background Trauma/hemorrhagic shock (T/HS) causes a release of pro-inflammatory mediators into the mesenteric lymph (ML) that may trigger a systemic inflammatory response and subsequent organ failure. Recently we showed that exosomes in post-shock ML are biologically active mediators of this inflammation. Because the specific inflammatory mediators in post-shock ML exosomes have yet to be characterized, we hypothesized that T/HS would lead to a distinct ML pro-inflammatory exosome phenotype that could be identified by proteomic analysis. We further hypothesized that their regulation by the neuro-enteric axis via the vagus nerve would modify this pro-inflammatory profile. Methods Male rats underwent an established T/HS model including 60 minutes of HS followed by resuscitation. ML was collected before HS (pre-shock) and after resuscitation (post-shock). A subset of animals underwent cervical vagus nerve electrical stimulation (VNS) after the HS phase. Liquid chromatography with tandem mass spectroscopy (LC-MS/MS) followed by protein identification, label free quantification, and bioinformatic analysis was performed on exosomes from the pre-shock and post-shock phases in the T/HS and T/HS+VNS groups. Biological activity of exosomes was evaluated using a monocyte NF-κB activity assay. Results ML exosomes express a distinct protein profile after T/HS with enrichment in pathways associated with cell signaling, cell death and survival, and the inflammatory response. Stimulation of the vagus nerve following injury attenuated the transition of ML exosomes to this T/HS-induced inflammatory phenotype with protein expression remaining similar to pre-shock. Monocyte NF-κB activity was increased after exposure to ML exosomes harvested after T/HS, while ML exosomes from pre-shock had no effect on monocyte NF-KB expression. Conclusion Post-shock ML exosomes carry a distinct, pro-inflammatory protein cargo. Stimulating the vagus nerve prevents the T/HS-induced changes in ML exosome protein payload, and suggests a novel mechanism by which the neuro-enteric axis may limit the systemic inflammatory response after injury. Level of Evidence This study is a Basic Science paper and therefore does not require a level of evidence. Conflicts of interest: None This paper is scheduled to be presented at the 77th Annual Meeting of the American Association for the Surgery of Trauma, San Diego, CA September 27, 2018. Corresponding Author: Todd W. Costantini, MD, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego Health, 200 W. Arbor Drive #8896, San Diego, CA 92103, tcostantini@ucsd.edu © 2018 Lippincott Williams & Wilkins, Inc.

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Tranexamic Acid Mediates Pro- and Anti-Inflammatory Signaling via Complement C5a Regulation in a Plasminogen Activator-Dependent Manner

Background Both tPA in the circulation and urokinase (uPA) in tissues cleave plasminogen to plasmin to promote clot lysis. TXA blocks both the tPA-dependent generation of plasmin on blood clots as well as active plasmin binding to polymerized fibrin, and is commonly administered for bleeding in trauma to limit fibrinolysis. In addition to lysing clots, however, active plasmin also cleaves Complement proteins, potentially enhancing inflammation. Because TXA does not block uPA-dependent plasmin generation from plasminogen and instead augments it, we hypothesized that administration of TXA could enhance or inhibit pro-inflammatory C5a formation in a plasminogen activator-dependent manner. Methods Citrate platelet-poor plasma (PPP) and PPP depleted of Complement Protein C3 or plasminogen (PLG) were obtained from healthy donors and commercial sources. PPP was treated ex vivo with -/+TXA and either -/+tPA or -/+uPA. Clotting was then induced by calcium and thrombin in clotted PPP experiments, while unclotted PPP experiments were treated with vehicle controls. C5a levels were measured via ELISA. Data were expressed as mean -/+SEM. Results Plasmin-mediated fibrinolysis by tPA in clotted PPP led to a ~3-fold increase in C5a production (p

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Characterizing the Underlying Diagnoses for Exploratory Laparotomies to Improve Risk-adjustment Models of Postoperative Mortality

Introduction Surgeons perform emergent exploratory laparotomies (ex-laps) for a myriad of surgical diagnoses. We characterized common diagnoses for which emergent ex-laps were performed and leveraged these groups to improve risk-adjustment models for postoperative mortality. Methods Using American Association for the Surgery of Trauma criteria, we identified hospitalizations where the primary procedure was an emergent ex-lap in the 2012-2014 (derivation cohort) and 2015 (validation cohort) Nationwide Inpatient Sample. After tabulating all ICD-9 diagnosis codes within these hospitalizations, we divided them into clinically-relevant groups. Using two stepwise regression paradigms – forward selection and backwards elimination – we identified diagnostic groups significantly associated with postoperative mortality in multivariable logistic regressions. We evaluated the addition of these groups as individual covariates in risk-adjustment models for postoperative mortality using the area under the receiver operator characteristic curve (AUROC). All regressions additionally adjusted for clinical factors and hospital clustering. Results We identified 4127 patients in the derivation cohort (median age: 50 years, 46.0% female, 62.1% white), with an overall mortality rate of 13.4%. Among all patients, we tabulated a total of 164 diagnosis codes, of which 27 (16.5%) may have led to an emergent ex-lap. These 27 codes clinically represented seven diagnostic categories, which captured a majority of the patients (70.4%). Backwards elimination and forward selection led to four common diagnosis categories associated with mortality: bleeding, obstruction, shock, and ischemia. Adjusting for these four diagnostic groups in a multivariable logistic regression assessing postoperative mortality increased the AUROC from 74.5% to 88.2% in the derivation cohort and from 73.8% to 88.2% in the validation cohort. Conclusion Seven diagnostic groups account for the majority of the emergent ex-laps. Adjusting for four groups may improve the accuracy of risk-adjustment models for mortality and validating such analytic standardization may optimize best research practices for EGS procedures. Evidence Level III, Prognostic and Epidemiologic Corresponding author: Joseph V. Sakran, MD, MPH, MPA, Department of Surgery, Division of Acute Care Surgery, Sheikh Zayed Tower, Suite 6107, Baltimore, MD 21287, Tel: 410-955-2244. Fax: 410-955-1884. Email: jsakran1@jhmi.edu © 2018 Lippincott Williams & Wilkins, Inc.

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Chief John M. Buckman III joins IamResponding as Director of Government and Regional Outreach

Dewitt, New York - IamResponding.com is pleased to announce that Chief John M. Buckman III has joined the IamResponding team as its new Director of Government and Regional Outreach. IamResponding is excited to have Chief Buckman join its team of emergency services professionals and looks forward to working with Chief Buckman to enhance its current product offerings, and to expand its current...

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Sepsis Alliance & NAEMT team-up to combat sepsis

Sepsis Alliance, the nation’s leading sepsis organization, and the National Association of Emergency Medical Technicians (NAEMT) are proud to announce their new partnership to combat sepsis and help save lives. Sepsis is the body’s life-threatening reaction to an infection. In the United States, sepsis affects 1.7 million people and takes 270,000 lives. As many as 87% of sepsis cases...

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Pulsara unveiling major new features of its platform at EMS World 2018 in Nashville

BOZEMAN, Mont. — Pulsara will be unveiling critical new elements of its technology during the EMS World Expo conference this week in Nashville. Pulsara provides a real-time communication network in hospitals and across entities and regions—driving quality improvement and better patient coordination. The technology solution is being used by regional healthcare systems across the U.S....

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PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be?

SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed.  However, the study still provides a wealth of information about SUP in the ICU.

EMCrit Project by Josh Farkas.

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PulmCrit- SUP-ICU: Is pantoprazole the elixir of life? Should it be?

SUP-ICU is a massive, modern RCT of stress ulcer prophylaxis (SUP) in the ICU. With 3298 patients, it is larger than many meta-analyses of SUP. Its primary mortality endpoint is deeply flawed.  However, the study still provides a wealth of information about SUP in the ICU.

EMCrit Project by Josh Farkas.

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The impact of Emergency Department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain

Anaesthesia

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Diagnostic and prognostic value of plasma volume status at Emergency Department admission in dyspneic patients: Results from the PARADISE cohort

Clinical Research in Cardiology

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Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting with Chest Pain – A Systematic Review and Meta‐Analysis

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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ED Chest Pain Rules: Follow Your HEART?

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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“Full Stomach” Despite the Wait: Point‐of‐Care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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Best practice guidelines for blunt cerebrovascular injury (BCVI)

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publi...

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A retrospective comparison between non-conveyed and conveyed patients in ambulance care

Not all patients where an ambulance is dispatched are conveyed to an emergency department. Although non-conveyance is a substantial part of ambulance care, there is limited insight in the non-conveyance patien...

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Albumin infusion in spontaneous bacterial peritonitis: another brick off the wall?

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Hemodynamic support in the early phase of septic shock: a review of challenges and unanswered questions

Improving sepsis support is one of the three pillars of a 2017 resolution according to the World Health Organization (WHO). Septic shock is indeed a burden issue in the intensive care units. Hemodynamic stabil...

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Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care

There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The ...

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Fluoroscopy-guided simultaneous distal perfusion as a preventive strategy of limb ischemia in patients undergoing extracorporeal membrane oxygenation

Limited data are available regarding prevention of limb ischemia in femorally cannulated patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). We investigated the association between strategy...

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Paramedic Chief Digital: How to improve patient and provider safety on the road

This issue features articles highlighting the importance of patient and provider safety during ambulance transport and the need for an EMS overhaul

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Rapid Response: Is EMS response different when the active shooter survives?

Despite the shooter’s despicable intent and multiple murders, he becomes another patient to triage, treat and transport

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Factors associated with pediatric non‐transport in a large EMS system

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis

JAMA

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The Las Vegas Mass Shooting: An analysis of blood component administration and blood bank donations

Background The deadliest mass shooting in modern United States history occurred October 1, 2017 in Las Vegas, killing 58 and overwhelming hospitals with over 600 injured. The scope of the tragedy offers insight into medical demands, which may help guide preparedness for future mass shooting incidents. Methods Retrospective, de-identified, healthcare institution-provided data from all hospitals and blood banks providing care to Las Vegas shooting victims was gathered. Study authors independently reviewed all data and cross-referenced it for verification. Main outcomes and measures include the number of victims requiring hospital and intensive care admission, the amount and types of blood components transfused during the first 24 hours, and the amount of blood donated to local blood banks following the Las Vegas mass shooting. Results 220 patients required hospital admission, 68 of them to critical care. Nearly 500 blood components were transfused during the first 24 hours in a red blood cell:plasma:platelet ratio of 1:0.54:0.81. Public citizens donated almost 800 units of blood immediately after the shooting; over 17% of this donated blood was wasted. Conclusions The amount of blood components transfused per patient admitted was similar in magnitude to other mass casualty events, and available blood supply met patient demand. The public call for blood donors was not necessary to meet immediate demand and led to resource waste. Preparation for future mass shooting incidents should include training the community in hemorrhage control, encouraging routine blood donation, and avoiding public calls for blood donation unless approved by local blood suppliers. Level of Evidence III Acknowledgments: The authors report no conflicts of interest. The work has neither been previously published nor is under consideration elsewhere. Corresponding author: M. James Lozada, D.O. Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Dr. | 4202 VUH, Nashville, TN 37232, james.lozada@vumc.org, @drjlozada, Fax: 615.343.1732, Telephone: 615.322.8476 © 2018 Lippincott Williams & Wilkins, Inc.

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Variation in Adjusted Mortality for Medical Admissions to Pediatric Cardiac ICUs

Objectives: Pediatric cardiac ICUs should be adept at treating both critical medical and surgical conditions for patients with cardiac disease. There are no case-mix adjusted quality metrics specific to medical cardiac ICU admissions. We aimed to measure case-mix adjusted cardiac ICU medical mortality rates and assess variation across cardiac ICUs in the Pediatric Cardiac Critical Care Consortium. Design: Observational analysis. Setting: Pediatric Cardiac Critical Care Consortium clinical registry. Patients: All cardiac ICU admissions that did not include cardiac surgery. Interventions: None. Measurements and Main Results: The primary endpoint was cardiac ICU mortality. Based on multivariable logistic regression accounting for clustering, we created a case-mix adjusted model using variables present at cardiac ICU admission. Bootstrap resampling (1,000 samples) was used for model validation. We calculated a standardized mortality ratio for each cardiac ICU based on observed-to-expected mortality from the fitted model. A cardiac ICU was considered a statistically significant outlier if the 95% CI around the standardized mortality ratio did not cross 1. Of 11,042 consecutive medical admissions from 25 cardiac ICUs (August 2014 to May 2017), the observed mortality rate was 4.3% (n = 479). Final model covariates included age, underweight, prior surgery, time of and reason for cardiac ICU admission, high-risk medical diagnosis or comorbidity, mechanical ventilation or extracorporeal membrane oxygenation at admission, and pupillary reflex. The C-statistic for the validated model was 0.87, and it was well calibrated. Expected mortality ranged from 2.6% to 8.3%, reflecting important case-mix variation. Standardized mortality ratios ranged from 0.5 to 1.7 across cardiac ICUs. Three cardiac ICUs were outliers; two had lower-than-expected (standardized mortality ratio 1) mortality. Conclusions: We measured case-mix adjusted mortality for cardiac ICU patients with critical medical conditions, and provide the first report of variation in this quality metric within this patient population across Pediatric Cardiac Critical Care Consortium cardiac ICUs. This metric will be used by Pediatric Cardiac Critical Care Consortium cardiac ICUs to assess and improve outcomes by identifying high-performing (low-mortality) centers and engaging in collaborative learning. Lauren Retzloff is now Lauren Bush. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/2gIrZ5Y). Supported, in part, by funding from the University of Michigan Congenital Heart Center, CHAMPS for Mott, and the Michigan Institute for Clinical & Health Research (National Institutes of Health/NCATS UL1TR002240). Dr. Gaies received support for article research from the National Institutes of Health/National Heart, Lung, and Blood Institute (K08HL116639). Dr. Costello disclosed that he has served on Pediatric Cardiac Critical Care Consortium’s Executive Committee for the last 5–6 year (unpaid, volunteer position). Ms. Zhang disclosed work for hire. Dr. Pasquali receives support from the Janette Ferrantino Professorship. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: mgaies@med.umich.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Increased 90-Day Mortality in Spontaneously Breathing Patients With Paraquat Poisoning: In Addition to Disease Severity, Lung Strain May Play a Role

Objectives: 1) To evaluate the prognostic roles of quantitative CT and pulmonary function tests and 2) to assess the association of dynamic strain and ventilation heterogeneity during unassisted spontaneous breathing with 90-day survival in patients with paraquat poisoning. Design: Prospective study. Setting: A university hospital ICU. Patients: One-hundred spontaneously breathing patients with paraquat poisoning without mechanical ventilation. Interventions: A standardized treatment protocol. Measurements and Main Results: Blood samples were collected to measure the plasma paraquat concentration upon arrival. CT scans at suspended inspiration and pulmonary function tests were performed at day 5. The weight of the poorly aerated lung compartment as a percentage of total lung weight (%Wpoor) was exponentially transformed, generating a new variable, Exp(%Wpoor/15). The functional residual capacity that was determined by helium dilution was used to calculate the dynamic strain (tidal volume/functional residual capacity by helium dilution method). Respiratory system reactance at 5 Hz was used as a marker of ventilation heterogeneity. Exp(%Wpoor/15) (adjusted hazard ratio, 2.58; 95% CI, 2.021–3.296; p

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Acute Phase Response in Critically Ill Elderly Burn Patients

Objectives: Survival of elderly burn patients remains unacceptably poor. The acute phase, defined as the first 96 hours after burn, includes the resuscitation period and influences subsequent outcomes and survival. The aim of this study was to determine if the acute phase response post burn injury is significantly different in elderly patients compared with adult patients and to identify elements contributing to adverse outcomes. Design: Cohort study. Setting: Tertiary burn center. Patients: Adult (

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Your guide to improving your EMS agency's safety culture (eBook)

Learn about the biggest drivers of transforming a fear-based culture into a Just Culture

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CC Nerd-The Case of the Subjective Truth

A recent post examining the utility of cricoid pressure and how to interpret non-inferiority trials stimulated discussion on Bayesian analysis and the question of whether a formal quantitative analysis is necessary or if an informal qualitative assessment is adequate. A recent reanalysis of the EOLIA trial published in JAMA by Goligher et al1 allows us to […]

EMCrit Project by Rory Spiegel.

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CC Nerd-The Case of the Subjective Truth

A recent post examining the utility of cricoid pressure and how to interpret non-inferiority trials stimulated discussion on Bayesian analysis and the question of whether a formal quantitative analysis is necessary or if an informal qualitative assessment is adequate. A recent reanalysis of the EOLIA trial published in JAMA by Goligher et al1 allows us to […]

EMCrit Project by Rory Spiegel.

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Randomized placebo‐controlled trial of droperidol and ondansetron for adult emergency department patients with nausea

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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Lung‐Protective Ventilation for Acute Respiratory Distress Syndrome

Academic Emergency Medicine, Volume 0, Issue ja, -Not available-.


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IBCC chapter & cast: Acute pancreatitis

Management of severe pancreatitis has remained in a state of controlled chaos and persistent debate for years (mirroring evolution in our treatment of septic shock).  This confusion shows no signs of abating in the near future.  This chapter explores a reasonable approach to pancreatitis, with the caveat that there is very little evidence available to guide our combat against this challenging foe.  

EMCrit Project by Josh Farkas.

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Tox and Hound – Dust To Dust

by Howard Greller Sudden sniffing death and myocardial sensitization I will show you fear in a handful of dust. – T.S. Eliot Little Johnny was having a hard time. Dumped by his girlfriend of eight glorious weeks, he was despondent. There wasn’t any alcohol in the house, and he didn’t have a fake ID or the […]

EMCrit Project by Tox & Hound.

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PulmCrit- Ketamine for alcohol withdrawal?

Recent publications have explored the role of ketamine in alcohol withdrawal.  Ketamine undoubtedly has some outstanding properties, which make it well suited for  this task.  The challenge is integrating ketamine into a unified, coherent treatment strategy. 

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Inferior Superiority

A perfect trial would require minimal statistical tools to assist in its analysis. Such a trial would be so large that the sample approached the true likeness of the broader population it intended to emulate, thus the risk of sampling error would be minimal. The confidence intervals surrounding the point estimates would be so minute, […]

EMCrit Project by Rory Spiegel.

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EMCrit #235 – Cardiac Arrest Science with Zack Shinar

Cardiac Arrest Science

EMCrit Project by Scott Weingart.

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IBCC chapter & cast: severe heart failure & cardiogenic shock

Management of severe heart failure and cardiogenic shock is difficult.  There is a notable lack of high-quality evidence regarding the sickest patients.  Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.   

EMCrit Project by Josh Farkas.

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Tox and Hound – Oh, the Nerve!

by Dan Rusyniak     OK, I am going to dive into this whole Russia controversy. Now before you go getting all political on me, I am not talking about the Muller probe. I am talking about the recent suspected poisoning of a former Russian Spy in England. While Russia has been the prime culprit […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Hypoglycemia

Severe hypoglycemia can be scary, especially when the patient isn't responding to front-line therapies (e.g. IV dextrose).  However, some unconventional tools and an organized approach can make this extremely manageable.

EMCrit Project by Josh Farkas.

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Tox and Hound – Toxicology’s Shapeshifter: Synthetic Cannabinoids

by Jeff Lapoint July, 2010. 3:14 am. “Jeff, I got a liddle case for ya”, said the voice of Lou (named changed), the very New York C-SPI from the Poison Center. “917-555-. . .” He continued to rattle off a phone number. “Dude, give me more than that”, I begged. I was a new fellow, […]

EMCrit Project by Tox & Hound.

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Tox and Hound – The Dantastic Mr. Tox & Howard – S02E04 – The Bloody Mess

The synthetic cannabinoid / brodifacoum outbreak with Dr. Steve Aks Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Steve Aks as they talk about one of the more concerning toxicologic outbreaks in recent memory – the exposure to brodifacoum through synthetic cannabinoid use. Although still ongoing, this crisis highlights the importance of teamwork […]

EMCrit Project by Tox & Hound.

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PulmCrit- Alcohol Withdrawal: One order to sedate them all

I should do a formal retrospective cohort study on this, but I don’t have time.  Fortunately, the ICU group at Northshore/Long Island Jewish has done exactly that.

EMCrit Project by Josh Farkas.

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EMCrit 234 – Pardon Me, I Couldn’t Help but Overhear or How to go from being an Ass-hole to an AYS-hole on Twitter

Are you saying?...

EMCrit Project by Scott Weingart.

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IBCC chapter & cast: Bradycardia

Bradycardia emergencies are uncommon, but these cases can go sideways fast.  An appropriately aggressive approach is needed to avoid cardiac arrest.  Sometimes the answer is as simple as the appropriate epinephrine dose.  

EMCrit Project by Josh Farkas.

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Tox and Hound – Snakes! Why’d it have to be SNAKES?

by Meghan Spyres Unless you suffer the over appreciated and never-ending summer of southern California, the warm weather season is winding down and fall is settling in. Though many will lament the end of iced coffees, sunny beaches, and carefree summer attire, for many toxicologists, we will quietly lament the end of snake season. Perhaps […]

EMCrit Project by Tox & Hound.

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EM Nerd-An Addendum to the Case of the Non-inferior Inferiority

Until recently the management of acute appendicitis has lay squarely in the hands of the surgeon. But there is a growing body of evidence examining the use of antibiotics alone in uncomplicated appendicitis. Most of the data exploring this question has found that the majority of patients treated with antibiotics alone will avoid surgery in […]

EMCrit Project by Rory Spiegel.

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IBCC chapter & cast: Acute pancreatitis

Management of severe pancreatitis has remained in a state of controlled chaos and persistent debate for years (mirroring evolution in our treatment of septic shock).  This confusion shows no signs of abating in the near future.  This chapter explores a reasonable approach to pancreatitis, with the caveat that there is very little evidence available to guide our combat against this challenging foe.  

EMCrit Project by Josh Farkas.

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Tox and Hound – Dust To Dust

by Howard Greller Sudden sniffing death and myocardial sensitization I will show you fear in a handful of dust. – T.S. Eliot Little Johnny was having a hard time. Dumped by his girlfriend of eight glorious weeks, he was despondent. There wasn’t any alcohol in the house, and he didn’t have a fake ID or the […]

EMCrit Project by Tox & Hound.

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PulmCrit- Ketamine for alcohol withdrawal?

Recent publications have explored the role of ketamine in alcohol withdrawal.  Ketamine undoubtedly has some outstanding properties, which make it well suited for  this task.  The challenge is integrating ketamine into a unified, coherent treatment strategy. 

EMCrit Project by Josh Farkas.

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EM Nerd-The Case of the Inferior Superiority

A perfect trial would require minimal statistical tools to assist in its analysis. Such a trial would be so large that the sample approached the true likeness of the broader population it intended to emulate, thus the risk of sampling error would be minimal. The confidence intervals surrounding the point estimates would be so minute, […]

EMCrit Project by Rory Spiegel.

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EMCrit #235 – Cardiac Arrest Science with Zack Shinar

Cardiac Arrest Science

EMCrit Project by Scott Weingart.

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IBCC chapter & cast: severe heart failure & cardiogenic shock

Management of severe heart failure and cardiogenic shock is difficult.  There is a notable lack of high-quality evidence regarding the sickest patients.  Treatment strategies validated among more stable patients may not be applicable to the most unstable heart failure patients.   

EMCrit Project by Josh Farkas.

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Tox and Hound – Oh, the Nerve!

by Dan Rusyniak     OK, I am going to dive into this whole Russia controversy. Now before you go getting all political on me, I am not talking about the Muller probe. I am talking about the recent suspected poisoning of a former Russian Spy in England. While Russia has been the prime culprit […]

EMCrit Project by Tox & Hound.

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IBCC chapter & cast – Hypoglycemia

Severe hypoglycemia can be scary, especially when the patient isn't responding to front-line therapies (e.g. IV dextrose).  However, some unconventional tools and an organized approach can make this extremely manageable.

EMCrit Project by Josh Farkas.

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Tox and Hound – Toxicology’s Shapeshifter: Synthetic Cannabinoids

by Jeff Lapoint July, 2010. 3:14 am. “Jeff, I got a liddle case for ya”, said the voice of Lou (named changed), the very New York C-SPI from the Poison Center. “917-555-. . .” He continued to rattle off a phone number. “Dude, give me more than that”, I begged. I was a new fellow, […]

EMCrit Project by Tox & Hound.

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Tox and Hound – The Dantastic Mr. Tox & Howard – S02E04 – The Bloody Mess

The synthetic cannabinoid / brodifacoum outbreak with Dr. Steve Aks Join Dan (@drusyniak) &Howard (@heshiegreshie) as they chat with Dr. Steve Aks as they talk about one of the more concerning toxicologic outbreaks in recent memory – the exposure to brodifacoum through synthetic cannabinoid use. Although still ongoing, this crisis highlights the importance of teamwork […]

EMCrit Project by Tox & Hound.

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PulmCrit- Alcohol Withdrawal: One order to sedate them all

I should do a formal retrospective cohort study on this, but I don’t have time.  Fortunately, the ICU group at Northshore/Long Island Jewish has done exactly that.

EMCrit Project by Josh Farkas.

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EMCrit 234 – Pardon Me, I Couldn’t Help but Overhear or How to go from being an Ass-hole to an AYS-hole on Twitter

Are you saying?...

EMCrit Project by Scott Weingart.

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IBCC chapter & cast: Bradycardia

Bradycardia emergencies are uncommon, but these cases can go sideways fast.  An appropriately aggressive approach is needed to avoid cardiac arrest.  Sometimes the answer is as simple as the appropriate epinephrine dose.  

EMCrit Project by Josh Farkas.

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Tox and Hound – Snakes! Why’d it have to be SNAKES?

by Meghan Spyres Unless you suffer the over appreciated and never-ending summer of southern California, the warm weather season is winding down and fall is settling in. Though many will lament the end of iced coffees, sunny beaches, and carefree summer attire, for many toxicologists, we will quietly lament the end of snake season. Perhaps […]

EMCrit Project by Tox & Hound.

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EM Nerd-An Addendum to the Case of the Non-inferior Inferiority

Until recently the management of acute appendicitis has lay squarely in the hands of the surgeon. But there is a growing body of evidence examining the use of antibiotics alone in uncomplicated appendicitis. Most of the data exploring this question has found that the majority of patients treated with antibiotics alone will avoid surgery in […]

EMCrit Project by Rory Spiegel.

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IBCC chapter & cast: community-onset pneumonia

Sir William Osler called pneumonia "the captain of the men of death."  Over a century later, pneumonia remains the leading cause of infectious death in the developed world.  

EMCrit Project by Josh Farkas.

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Guardian Angel debuts Elite Series personal safety lighting devices for first responders

The new design is to increase the visibility of first responders as they attend to roadside incidents

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Instructor, EMS - Gateway Technical College

The Instructor, EMS, will teach EMS courses at all levels and teach Paramedic classes using the Department of Health Services (DHS) curricula - assist in the delivery of all pre-hospital EMS didactic and lab skills at the Paramedic level. This position reports to the Dean, School of Protective & Human Services. Responsibilities: - Plan and teach courses which fulfill the current curriculum goals and ...

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Low-dose magnesium sulfate vs high dose in the early management of rapid atrial fibrillation: Randomized controlled double-blind study (LOMAGHI Study)

Academic Emergency Medicine

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A Pediatric Emergency Department intervention to increase contraception initiation among adolescents

Academic Emergency Medicine

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Volatile Organic Compounds in Patients With Acute Kidney Injury and Changes During Dialysis

Objectives: To characterize volatile organic compounds in breath exhaled by ventilated care patients with acute kidney injury and changes over time during dialysis. Design: Prospective observational feasibility study. Setting: Critically ill patients on an ICU in a University Hospital, Germany. Patients: Twenty sedated, intubated, and mechanically ventilated patients with acute kidney injury and indication for dialysis. Interventions: Patients exhalome was evaluated from at least 30 minutes before to 7 hours after beginning of continuous venovenous hemodialysis. Measurements and Main Results: Expired air samples were aspirated from the breathing circuit at 20-minute intervals and analyzed using multicapillary column ion-mobility spectrometry. Volatile organic compound intensities were compared with a ventilated control group with normal renal function. A total of 60 different signals were detected by multicapillary column ion-mobility spectrometry, of which 44 could be identified. Thirty-four volatiles decreased during hemodialysis, whereas 26 remained unaffected. Forty-five signals showed significant higher intensities in patients with acute kidney injury compared with control patients with normal renal function. Among these, 30 decreased significantly during hemodialysis. Volatile cyclohexanol (23 mV; 25–75th, 19–38), 3-hydroxy-2-butanone (16 mV, 9–26), 3-methylbutanal (20 mV; 14–26), and dimer of isoprene (26 mV; 18–32) showed significant higher intensities in acute kidney impairment compared with control group (12 mV; 10–16 and 8 mV; 7–14 and not detectable and 4 mV; 0–6; p

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Readmission after antibiotic management of uncomplicated acute appendicitis in adults: prospective study

Abstract

Background

Acute appendicitis is the most common surgical cause of acute abdomen. Many randomized studies compare between antibiotic and surgery, and such studies indicated that antibiotics might treat acute appendicitis. However, there are concerns about selection bias in previous studies. Hence, to overcome this worry; we used in this study a full-scale population-based application.

Patients and methods

We identified 327 adult patients who were admitted to surgical ward with diagnosis of uncomplicated acute appendicitis between March 2013 and February 2016. All patients received antibiotic therapy after confirming the diagnosis by computed tomography. Endpoints were treatment efficacy, readmission, and complications in 1 year of follow-up.

Results

Of the 327 patients include in this study, 8 (2.5%) patients failed initial non-operative (antibiotic) management and underwent operation during their initial hospitalization. Of 319 available for 1-year follow-up, 280 patients (87.8%) did not require appendectomy; while 39 patients (12.2%) need readmission within 1 year.

Conclusions

Antibiotics are a safe and visible option in acute appendicitis management. This approach needs careful assessment and evaluation for each individual patient before it is used as the first-line therapy.

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Acute Kidney Injury in Critically Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A Retrospective Study

Objectives: Acute kidney injury in the critically ill pediatric population is associated with worse outcome. The aim of this study was to assess the prevalence, associated clinical variables, and outcomes of acute kidney injury in children admitted to the PICU with diabetic ketoacidosis. Design: Retrospective cohort. Setting: PICU of a tertiary, university affiliated, pediatric medical center. Patients: All children less than age 18 years with a primary diagnosis of diabetic ketoacidosis admitted to the PICU between November 2004 and October 2017. Interventions: None. Measurements and Main Results: Acute kidney injury was categorized into three stages using the Kidney Disease Improving Global Outcomes scale. Of the 82 children who met the inclusion criteria, 24 (30%) had acute kidney injury: 18 (75%) stage 1, five (21%) stage 2, and one (4%) stage 3. None needed renal replacement therapy. Compared with the patients without acute kidney injury, the acute kidney injury group was characterized by higher mean admission serum levels of sodium (143.25 ± 9 vs 138.6 ± 4.9 mmol/L; p = 0.0035), lactate (29.4 ± 17.1 vs 24.1 ± 10.8 mg/dL; p = 0.005), and glucose (652 ± 223 vs 542 ± 151 mg/dL; p = 0.01). There was no between-group difference in length of PICU stay (1.38 ± 0.7 vs 1.4 ± 0.7 d; p = 0.95) or hospitalization (6.1 ± 2.1 vs 5.8 ± 5.6 d; p = 0.45). Kidney injury was documented at discharge in four patients with acute kidney injury (16.7%), all stage 1; all had normal creatinine levels at the first clinical outpatient follow-up. All 82 patients with diabetic ketoacidosis survived. Conclusions: In this study, acute kidney injury was not uncommon in children with diabetic ketoacidosis hospitalized in the PICU. However, it was usually mild and not associated with longer hospitalization or residual kidney injury. Dr. Weissbach and Mrs. Zur contributed equally to this work. The authors have disclosed that they do not have any potential conflicts of interest. This work was performed in partial fulfillment of the MD thesis requirements of Sackler Faculty of Medicine for Mrs. Zur. For information regarding this article, E-mail: weissbac@gmail.com. ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Empyema Commission of 1918 – Impact on Acute Care Surgery 100 Years Later

No abstract available

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Pyoderma Gangrenosum Misdiagnosis Resulting in Amputation: A Review

Pyoderma Gangrenosum (PG) is a rare, ulcerative cutaneous disorder typically affecting the lower extremities. The clinical appearance of PG can mimic various cutaneous infections and neoplasms, leading to misdiagnosis and mistreatment including unnecessary surgical interventions such as debridements and even amputations. Diagnostic criteria exist, including characteristic clinical appearance and the exclusion of other diagnoses, however no definitive test exists to confirm the diagnosis of PG. We have sought to differentiate between the clinical characteristics of patients with PG and diseases that mimic PG resulting in amputation or were considered for amputation. We evaluated published cases where patients with PG were mistaken for other conditions resulting in impending (near miss) amputation or complete amputation. Fourteen cases of PG were found in which amputation was considered for treatment or erroneously underwent amputation. In six cases a total or partial amputation was erroneously performed, while in other eight patients, amputation was considered before the correct diagnosis of PG was made. PG was most commonly misdiagnosed as soft tissue infection (e.g. necrotizing fasciitis) in patients who were considered for or underwent amputation. Lesions appearing in atypical sites such as the hands and the genitalia were major predisposing factors for misdiagnosis. The identification of inflammatory comorbid conditions and the absence of positive microbiological cultures favor the diagnosis of PG. Finally, consulting dermatology in patients with ulcers that are refractory to treatment with antibiotics and/or debridement is indicated to confirm the diagnosis of PG, as a dermatology consult resulted in avoidance of amputation in all of cases reviewed. Study Type Review Article Level of Evidence V – A review article of relevant published case reports as it relates to the diagnosis and management of pyoderma gangrenosum. Corresponding Author: Alex G. Ortega Loayza, MD. Department of Dermatology, Oregon Health & Science University, Address: CH-16, 3303 SW Bond Ave, Portland, OR, 97239, Telephone: 503-494-2121 Email: ortegalo@ohsu.edu Sources of Funding: Gerlinger Endowment and Medical Research Foundation of Oregon granted to AGOL Conflicts of Interest: There are no conflicts of interest among the authors involved in the creation of this manuscript. © 2018 Lippincott Williams & Wilkins, Inc.

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Pre-hospital tourniquet use in penetrating extremity trauma: decreased blood transfusions and limb complications

Background Despite increasing popularity of pre-hospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if pre-hospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group. Methods An eight-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a level I trauma center. Patients with pre-hospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups. Results A total of 204 patients were matched with 127 (62.3%) in the pre-hospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the ED was 22.5+1.3 minutes. Patients in the TQ group had higher average SBP on arrival in the ED (120+2 vs. 112+2, p=0.003). TQ group required less total PRBCs (2.0+0.1 vs. 9.3+0.6, p

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OPTIMAL TIMING OF DELAYED EXCRETORY PHASE CT SCAN FOR DIAGNOSIS OF URINARY EXTRAVASATION AFTER HIGH-GRADE RENAL TRAUMA

Introduction Excretory phase CT scan is used for diagnosis of renal collecting system injuries and accurate grading of high-grade renal trauma (HGRT). However, optimal timing of the excretory phase is not well-established. We hypothesized that there is an association between excretory phase timing and diagnosis of urinary extravasation and aimed to identify the optimal excretory phase timing for diagnosis of urinary extravasation. Methods The Genito-Urinary Trauma Study collected data on HGRT (grades III-V) from 14 Level-1 trauma centers between 2014 and 2017. The time between portal venous and excretory phases at initial CT scans was recorded. Poisson regression was used to measure the association between excretory phase timing and diagnosis of urinary extravasation. Predictive receiver operating characteristic analysis was used to identify a cut-off point optimizing detection of urinary extravasation. Results Overall, 326 patients were included; 245 (75%) had excretory phase CT scans for review either initially (n=212) or only at their follow-up (n=33). At initial CT with excretory phase, 46 of 212 patients (22%) were diagnosed with urinary extravasation. Median time between portal venous and excretory phases was 4 minutes (IQR: 4 –7 minutes). Time of initial excretory phase was significantly greater in those diagnosed with urinary extravasation. Increased time to excretory phase was positively associated with finding urinary extravasation at the initial CT scan after controlling for multiple factors (Risk Ratio per minute: 1.15, 95% CI: 1.09-1.22, P

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Changes in Exhaled 13CO2/12CO2 Breath Delta Value as an Early Indicator of Infection in ICU Patients

Background We have developed a new, non-invasive predictive marker for onset of infection in surgical ICU patients. The exhaled 13CO2/12CO2 ratio, or breath delta value (BDV), has been shown to be an early marker for infection in a proof of concept human study and in animal models of bacterial peritonitis. In these studies, the BDV changes during onset and progression of infection, and these changes precede physiological changes associated with infection. Earlier diagnosis and treatment will significantly reduce morbidity, mortality, hospitalization costs, and length of stay. The objective of this prospective, observational, multi-center study was to determine the predictive value of the BDV as an early diagnostic marker of infection. Methods Critically ill adults after trauma or acute care surgery with an expected length of stay of >5 days were enrolled. The BDV was obtained every 4 hours for 7 days and correlated to clinical infection diagnosis, serum C-reactive protein and Procalcitonin levels. Clinical infection diagnosis was made by an independent endpoint committee. This trial was registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT02327130. Results Groups were demographically similar (n=20). Clinical infection diagnosis was confirmed on day 3.9 ± 0.63. Clinical suspicion of infection (defined by SIRS criteria and/or new antibiotic therapy), was on day 2.1 ± 0.5 in all infected patients. However, 5 of 9 (56%) non-infected subjects also met clinical suspicion criteria. The BDV significantly increased by 1-1.7‰ on day 2.1 after enrollment (p1.4‰ accurately differentiates subjects who develop infections from those who do not and predicts the presence of infection up to 48 hours before clinical confirmation. The BDV may predict the onset of infection and aid in distinguishing SIRS from infection, which could prompt earlier diagnosis, earlier appropriate treatment, and improve outcomes. Level of Evidence Level II, diagnostic test Corresponding Author: Ann P. O’Rourke; orourke@surgery.wisc.edu, 600 Highland Ave, Madison, WI 53792, (608) 262-6246 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery September 13-16, 2017 in Baltimore, MD Oral Presentation Friday September 15, 2017 Disclosure statements: The work reported in this manuscript was by sponsored by Isomark, LLC, Madison, WI, USA. Daniel E. Bütz declares an ownership interest in Isomark, LLC, a company that licenses technologies discussed in this manuscript. Funding support for research related costs was provided by Isomark, LLC. All other authors declare no conflicts of interest. © 2018 Lippincott Williams & Wilkins, Inc.

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The Impact of Pre Hospital Administration of Freeze Dried Plasma on Casualty Outcome

Background Hemorrhage is the most common preventable cause of death in both civilian and military trauma. There is no consensus regarding the appropriate fluid resuscitation protocol. Plasma, as a resuscitative fluid, has substantial benefits as a volume expander, owing to its relatively high oncotic pressure and its positive effect on trauma induced coagulopathy by replenishing the lost coagulation factors, rather than diluting the casualty’s remaining factors. The Israel Defense Force Medical Corps decided to use Freeze dried plasma (FDP) as the fluid of choice for casualties in hemorrhagic shock in the prehospital setting. The Aim of our study is to compare the differences of coagulation, perfusion measurements, resource utilization, and outcome between casualties receiving FDP to casualties who didn’t receive FDP in the prehospital setting. Methods This is a retrospective matched cohort study based on two groups of casualties (those treated with FDP vs. those without FDP treatment). The control group was compiled in three steps of precision for age, gender, mechanism of injury and maximum level of severity for each nine injured body regions. Data were collected from the IDF Trauma Registry and The National Israel Trauma Registry. Results The study group comprised 48 casualties receiving FDP and 48 controls with no differences in demographic, evacuation time and injury characteristics. The FDP group demonstrated a lower level of hemoglobin (12.7 gr/dzl) (OR 3.11 95%CI 1.10-8.80), lower level of INR (1.1) (OR 3.09 95%CI 1.04-9.14) and lower level of platelets (230x109/L) (OR 3.06 95%CI 1.16-8.06). No other differences were found between the two groups. Conclusion The use of FDP in the prehospital setting has logistic benefits and a positive effect on coagulation profile, with no other significant effectsn. Future studies need to be done on larger groups in order to verify trends or nullify our hypotheses. Level of Evidence IV Study type retrospective matched cohort study Israel Trauma Group (ITG) includes: Alfici R, Bahouth H, Becker A, Jeroukhimov I, Karawani I, Kessel B, Klein Y, Lin G, Merin O, Miklosh B, Mnouskin Y, Rivkind A, Shaked G, Sivak G, Soffer D, Stein M, and Weiss M. Equally contributing first author, Shlaifer Amir MD, Siman-Tov Maya PhD Corresponding Author's contact information: Amir Shlaifer MD, MHA, Address: Surgeon General’s Headquarters, Military POB 02149, Israel Defense Forces, 02149, Israel, Telephone Numbers: Mobile - (+) 972-52-7360803, Office - (+)972-3-5401150, Email: shlaifer.md@gmail.com Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Conference Presentation: None Conflict of interest: The authors declare no conflict of interest. Disclosures of funding received for this work: Research reported in this publication was supported by the Israel Defense Forces (IDF) Medical Corps and Directorate of Defense Research & Development, Israeli Ministry of Defense (IMOD DDR&D) © 2018 Lippincott Williams & Wilkins, Inc.

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Initial Evaluation of the Efficacy and Safety of In-Hospital Expandable Hemostatic Minisponge Use In Penetrating Trauma

Background Hemorrhage remains the leading cause of preventable death after trauma. The XSTAT® expandable minisponge hemostatic device was developed for the control of severe, life-threatening bleeding from junctional wounds not amenable to tourniquet application. This is an initial report of the clinical use of this novel method of hemorrhage control for civilian penetrating injury. Methods A review of trauma admissions at a high volume level 1 trauma center was carried out from July 2016 to November 2017. All patients sustaining penetrating trauma with active hemorrhage were evaluated for XSTAT® use. Ten device deployments occurred during this time. Each deployment was reviewed in detail, capturing patient and injury data, efficacy of hemorrhage control, and evaluation of any potential device or treatment related complications. Results 6,363 trauma admissions were reviewed with 22.1% sustaining a penetrating mechanism of injury. XSTAT® was deployed in 10 (0.7%) penetrating trauma admissions with a mean age of 38.3 (range 16 – 59) years, SBP of 126.7 (range 74 – 194) mmHg, GCS 14.5 (range 13 – 15) and NISS of 9.5 (range 1 – 27). Eight patients had an identifiable arterial injury; the remainder had vein or soft tissue bleeding. Overall, half were junctional injuries. XSTAT® was able to stop bleeding in nine of ten patients on the first deployment, with the remaining patient requiring one repeat injection. Dwell times ranged from 1 to 40 hours (median = 15 h). There were no technical device failures or embolic complications. Retained sponges were identified in two patients on initial post removal x-rays following wound exploration for definitive hemorrhage control and sponge removal. No patient died during the study period. Conclusions XSTAT® use appears safe. It is rapid, reliable, and provides a high degree of hemorrhage control on first deployment. Sponge removal should always be followed by radiographic clearance. For patients with hemorrhage from cavitary wounds not amenable to tourniquet placement, this device was effective. Further study is warranted as XSTAT® use becomes more widespread. Level of Evidence V Study Type Case series Address for Correspondence and Reprints: Kenji Inaba, MD, FRCSC, FACS, Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA 90033, Phone: (323) 409-8597, Fax: (323) 441-9907. E-mail: kinaba@surgery.usc.edu Conflict of Interest The authors have no conflicts of interest or disclosures of funding to declare. © 2018 Lippincott Williams & Wilkins, Inc.

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The Incidence and Associations of Acute Kidney Injury in Trauma Patients Admitted to Critical Care: A Systematic Review and Meta-analysis

Background As more patients are surviving the initial effects of traumatic injury clinicians are faced with managing the systemic complications of severe tissue injury. Of these acute kidney injury (AKI) may be a sentinel complication contributing to adverse outcomes. Objective To establish the incidence of AKI in patients admitted to critical care after major trauma, to explore any risk factors and to evaluate the association of AKI with outcomes. Data Sources Systematic search of MEDLINE, EMBASE and Cochrane library from January 2004 to April 2018. Study Selection Studies of adult major trauma patients admitted to critical care that applied consensus AKI criteria (RIFLE, AKIN or KDIGO) and reported clinical outcomes were assessed (PROSPERO Registration: CRD42017056781). Of the 35 full-text articles selected from the screening, 17 studies (48.6%) were included. Data Extraction and Synthesis We followed the PRISMA guidelines and study quality was assessed using the Newcastle-Ottawa score. The pooled incidence of AKI and relative risk of death were estimated using random-effects models. Main Outcomes and Measures Incidence of AKI was the primary outcome. The secondary outcome was study-defined mortality. Results We included 17 articles describing AKI outcomes in 24,267 trauma patients. The pooled incidence of AKI was 20.4% (95% CI 16.5-24.9). Twelve studies reported the breakdown of stages of AKI with 55.7% of patients classified as RIFLE-R or Stage 1, 30.3% as RIFLE-I or Stage 2 and 14.0% as RIFLE-F or Stage 3. The pooled relative risk of death with AKI compared was 3.6 (CI 2.4-5.3). In addition, there was a concordant increase in odds of death among six studies that adjusted for multiple variables (adjusted OR 1.5 [95% CI 1.3-1.8]; p=

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