Chad M. Cannon

Utility of the shock index in predicting mortality in traumatically injured patients.

BACKGROUND Currently, specific triage criteria, such as blood pressure, respiratory status, Glasgow Coma Scale, and mechanism of injury are used to categorize trauma patients and prioritize emergency department (ED) and trauma team responses. It has been demonstrated in previous literature that an abnormal shock index (SI = heart rate [HR]/systolic blood pressure, >0.9) portends a worse outcome in critically ill patients. Our study looked to evaluate the SI calculated in the field, on arrival to the ED, and the change between field and ED values as a simple and early marker to predict mortality in traumatically injured patients. METHODS A retrospective chart review of the trauma registry of an urban level I trauma center. Analysis of 2,445 patients admitted over 5 years with records in the trauma registry of which 1,166 also had data for the field SI. An increase in SI from the field to the ED was defined as any increase in SI regardless of the level of the magnitude of change. RESULTS Twenty-two percent of patients reviewed had an ED SI >0.9, with a mortality rate of 15.9% compared with 6.3% in patients with a normal ED SI. An increase in SI between the field and ED signaled a mortality rate of 9.3% versus 5.7% for patients with decreasing or unchanged SI. Patients with an increase in SI of >or=0.3 had a mortality rate of 27.6% versus 5.8% for patients with change in SI of <0.3. CONCLUSION Trauma patients with SI >0.9 have higher mortality rates. An increase in SI from the field to the ED may predict higher mortality. The SI may be a valuable addition to other ED triage criteria currently used to activate trauma team responses.

Copeptin Helps in the Early Detection of Patients With Acute Myocardial Infarction Primary Results of the CHOPIN Trial (Copeptin Helps in the early detection Of Patients with acute myocardial INfarction)

OBJECTIVES The goal of this study was to demonstrate that copeptin levels <14 pmol/L allow ruling out acute myocardial infarction (AMI) when used in combination with cardiac troponin I (cTnI) <99 th percentile and a nondiagnostic electrocardiogram at the time of presentation to the emergency department (ED). BACKGROUND Copeptin is secreted from the pituitary early in the course of AMI. METHODS This was a 16-site study in 1,967 patients with chest pain presenting to an ED within 6 hours of pain onset. Baseline demographic characteristics and clinical data were collected prospectively. Copeptin levels and a contemporary sensitive cTnI (99 th percentile 40 ng/l; 10% coefficient of variation 0.03 μg/l) were measured in a core laboratory. Patients were followed up for 180 days. The primary outcome was diagnosis of AMI. Final diagnoses were adjudicated by 2 independent cardiologists blinded to copeptin results. RESULTS AMI was the final diagnosis in 156 patients (7.9%). A negative copeptin and cTnI at baseline ruled out AMI for 58% of patients, with a negative predictive value of 99.2% (95% confidence interval: 98.5 to 99.6). AMIs not detected by the initial cTnI alone were picked up with copeptin >14 pmol/l in 23 (72%) of 32 patients. Non-ST-segment elevation myocardial infarctions undetected by cTnI at 0 h were detected with copeptin >14 pmol/l in 10 (53%) of 19 patients. Projected average time-to-decision could be reduced by 43% (from 3.0 h to 1.8 h) by the early rule out of 58% of patients. Both abnormal copeptin and cTnI were predictors of death at 180 days (p < 0.0001 for both; c index 0.784 and 0.800, respectively). Both were independent of age and each other and provided additional predictive value (all p < 0.0001). CONCLUSIONS Adding copeptin to cTnI allowed safe rule out of AMI with a negative predictive value >99% in patients presenting with suspected acute coronary syndromes. This combination has the potential to rule out AMI in 58% of patients without serial blood draws.

The GENESIS Project (GENeralized Early Sepsis Intervention Strategies) A Multicenter Quality Improvement Collaborative

Background: Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in community and tertiary care settings. Methods: This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GENESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB not achieved after GENESIS) group and treatment (patients treated after GENESIS and RB achieved after GENESIS) group for comparison. Results: The control group comprised 1554 patients not receiving the RB (952 before GENESIS and 602 RB not achieved after GENESIS). The treatment group comprised 4801 patients receiving the RB (4109 after GENESIS and 692 RB achieved after GENESIS). Patients receiving the RB (treatment group) experienced an in-hospital mortality reduction of 14% (42.8%-28.8%, P < .001) and a 5.1 day decrease in hospital length of stay (20.7 vs 15.6, P < .001) compared to those not receiving the RB (control group). Similar mortality reductions were seen in the before-and-after (43% vs 29%, P < .001) or concurrent RB not achieved versus achieved (42.5% vs 27.2%, P < .001) subgroup comparisons. Conclusions: Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay. These findings remained consistent when examined in both before-and-after and concurrent analyses. Early sepsis intervention strategies are associated with 1 life being saved for every 7 treated.

CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department

IntroductionOur purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension.MethodsMulticenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures ≥180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP ± 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment.ResultsOf 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P = 0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P = 0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P = 0.183). Labetalol patients had slower heart rates at all time points (P < 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P = 0.028; C stat for model = 0.72)ConclusionsPatients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.Trial registrationClinicalTrials.gov: NCT00765648

Rapid Emergency Medicine Score (REMS) in the trauma population: a retrospective study

Objective Rapid Emergency Medicine Score (REMS) is an attenuated version of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and has utility in predicting mortality in non-surgical patients, but has yet to be tested among the trauma population. The objective was to evaluate REMS as a risk stratification tool for predicting in-hospital mortality in traumatically injured patients and to compare REMS accuracy in predicting mortality to existing trauma scores, including the Revised Trauma Score (RTS), Injury Severity Score (ISS) and Shock Index (SI). Design and setting Retrospective chart review of the trauma registry from an urban academic American College of Surgeons (ACS) level 1 trauma centre. Participants 3680 patients with trauma aged 14 years and older admitted to the hospital over a 4-year period. Patients transferred from other hospitals were excluded from the study as were those who suffered from burn or drowning-related injuries. Patients with vital sign documentation insufficient to calculate an REMS score were also excluded. Primary outcome measures The predictive ability of REMS was evaluated using ORs for in-hospital mortality. The discriminate power of REMS, RTS, ISS and SI was compared using the area under the receiver operating characteristic curve. Results Higher REMS was associated with increased mortality (p<0.0001). An increase of 1 point in the 26-point REMS scale was associated with an OR of 1.51 for in-hospital death (95% CI 1.45 to 1.58). REMS (area under the curve (AUC) 0.91±0.02) was found to be similar to RTS (AUC 0.89±0.04) and superior to ISS (AUC 0.87±0.01) and SI (AUC 0.55±0.31) in predicting in-hospital mortality. Conclusions In the trauma population, REMS appears to be a simple, accurate predictor of in-hospital mortality. While REMS performed similarly to RTS in predicting mortality, it did outperform other traditionally used trauma scoring systems, specifically ISS and SI.

Identifying Severe Sepsis via Electronic Surveillance

An electronic sepsis surveillance system (ESSV) was developed to identify severe sepsis and determine its time of onset. ESSV sensitivity and specificity were evaluated during an 11-day prospective pilot and a 30-day retrospective trial. ESSV diagnostic alerts were compared with care team diagnoses and with administrative records, using expert adjudication as the standard for comparison. ESSV was 100% sensitive for detecting severe sepsis but only 62.0% specific. During the pilot, the software identified 477 patients, compared with 18 by adjudication. In the 30-day trial, adjudication identified 164 severe sepsis patients, whereas ESSV detected 996. ESSV was more sensitive but less specific than care team or administrative data. ESSV-identified time of severe sepsis onset was a median of 0.00 hours later than adjudication (interquartile range = 0.05). The system can be a useful tool when implemented appropriately but lacks specificity, largely because of its reliance on discreet data fields.

Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial

Objective To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). Design Secondary analysis of the multicentre prospective, randomised CLUE trial. Setting 13 academic emergency departments in the USA. Participants Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. Interventions Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved. Primary outcome measure Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician. Results Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197–226) mm Hg) and labetalol (210 (200–226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). Conclusions In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. Clinical Trial Registration NCT00765648, clinicaltrials.gov

The management of acute hypertension in patients with renal dysfunction: labetalol or nicardipine?

Abstract Study Objectives: To compare the safety and efficacy of US Food and Drug Administration (FDA)-recommended doses of labetalol and nicardipine for hypertension (HTN) management in a subset of patients with renal dysfunction (RD). Design: Randomized, open label, multicenter prospective clinical trial. Setting: Thirteen United States tertiary care emergency departments. Patients or Participants: Subgroup analysis of the Evaluation of IV Cardene (Nicardipine) and Labetalol Use in the Emergency Department (CLUE) clinical trial. The subjects were 104 patients with RD (ie, creatinine clearance < 75 mL/min) who presented to the emergency department with a systolic blood pressure (SBP) ≥ 180 mmHg on 2 consecutive readings and for whom the emergency physician felt intravenous antihypertensive therapy was desirable. Interventions: The FDA recommended doses of either labetalol or nicardipine for HTN management. Measurements: The number of patients achieving the physicians predefined target SBP range within 30 minutes of treatment. Results: Patients treated with nicardipine were within target range more often than those receiving labetalol (92% vs 78%, P = 0.046). On 6 SBP measures, patients treated with nicardipine were more likely to achieve the target range on either 5 or all 6 readings than were patients treated with labetalol (46% vs 25%, P = 0.024). Labetalol patients were more likely to require rescue medication (27% vs 17%, P = 0.020). Adverse events thought to be related to either treatment group were not reported in the 30-minute active study period, and patients had slower heart rates at all time points after 5 minutes (P < 0.01). Conclusions: In severe HTN with RD, nicardipine-treated patients are more likely to reach a target blood pressure range within 30 minutes than are patients receiving labetalol. Clinical Implications: Within 30 minutes of administration, nicardipine is more efficacious than labetalol for acute blood pressure control in patients with RD.

Rash from levamisole vasculopathy in a cocaine abuser.

A 40-year-old woman presented to the Emergency Department for evaluation of nose and bilateral ear rash. The rash had begun approximately 1 week before presentation. She denied medical history or allergies and was taking no medications. She initially denied any recent substance abuse, then later admitted to a history of and continued use of marijuana and cocaine. Physical examination revealed an otherwise healthyappearing female with normal vital signs. The patient had a nontender, stellate, purpuric, macular rash with mild surrounding erythema involving the lobules and helices of both ears (Figures 1–4). A milder form of the same lesion appeared on both sidewalls of the nose superior to the ala (Figure 5). Internal ear examinations were normal, and a focal area of anterior cartilaginous bleeding was noted in right nare. An examination of the rest of her body revealed no other skin abnormalities. Her urine drug screen returned positive for tetrahydrocannabinol and cocaine. A urine specimen was sent for levamisole testing at an outside laboratory and returned positive at a later date with a concentration of 1.8mg/mL,with 0.10mg/mL used as the positive reference value. White blood cell and neutrophil counts were within normal ranges. Perinuclear anti-neutrophil cytoplasmic antibody (ANCA) levels returned positive after discharge with titer >1280, cytoplasmic ANCAwas negative.

Necessity of hospitalization and stress testing in low risk chest pain patients

Background: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI < 0.040 &mgr;g/l and copeptin < 14 pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow‐up potentially including stress testing. Methods: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(< 0.040 &mgr;g/l) and copeptin < 14 pmol/l at presentation and after 2 h were considered “low risk” and selected for further analysis. Results: None of the 475 “low risk” patients were diagnosed with MI during the 180 day follow‐up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%–100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the “low risk” group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%–9.7%] versus 0.5%[95%CI:0.0%–2.9%], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%–74.0%] vs 22.9%[95%CI:17.1%–29.6%], p < .001). Those tested had less cardiac rehospitalizations during follow‐up (1.7% vs 5.1%, p = .040). Conclusions: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180 days. These low risk patients may be candidates for early outpatient testing and cardiology follow‐up thereby reducing hospitalization.