Ediza Giraldez

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

INTRODUCTION The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients. METHODS This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Students t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level. RESULTS Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively). CONCLUSION This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Precision and reliability of the Glasgow Coma Scale score among a cohort of Latin American prehospital emergency care providers.

INTRODUCTION The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness in patients with head injuries. Rapid and accurate GCS scoring is essential for adequate assessment and treatment of critically sick and injured patients. This study sought out to determine the precision and reliability of the GCS among a cohort of Latin American Critical Care Transport Providers. METHODS The study consisted of a cross-sectional design using an Internet-based examination. The evaluation consisted of four focused clinical scenarios with a classification based on severity. For measurement of intra-rater reliability the first and fourth cases were identical. Five minutes were allocated for each scenario. For categorical variables, chi-square testing and Fishers exact testing were used to assess associations. For all tests, statistical significance was set at the 0.05 level. RESULTS A total of 62 providers participated, including 17 physicians and 45 advanced providers (nurses and paramedics). No statistically significant differences were observed between physicians and advanced providers in the correct classification of the individual scenarios. Five of the 17 physicians (29.4%) answered all cases correctly, while none of the 45 advanced providers did (p < 0.001). When evaluating the duplicated cases (Cases 1 and 4), five physicians (29.4%) and 11 advanced providers (24.4%) correctly classified the cases. This difference was not statistically significant. CONCLUSIONS This study demonstrated a poor precision and poor reliability in the use of the Glasgow Coma Scale within the study subjects.

Prehospital Sepsis Project (PSP): Knowledge and Attitudes of United States Advanced Out-of-Hospital Care Providers

INTRODUCTION Severe sepsis and septic shock are common and often fatal medical problems. The Prehospital Sepsis Project is a multifaceted study that aims to improve the out-of-hospital care of patients with sepsis by means of education and enhancement of skills. The objective of this Project was to assess the knowledge and attitudes in the principles of diagnosis and management of sepsis in a cohort of United States out-of-hospital care providers. METHODS This was cross-sectional study. A 15-item survey was administered via the Web and e-mailed to multiple emergency medical services list-servers. The evaluation consisted of four clinical scenarios as well as questions on the basics of sepsis. For intra-rater reliability, the first and the fourth scenarios were identical. Chi-square and Fishers Exact testing were used to assess associations. Relative risk (RR) was used for strength of association. Statistical significance was set at .05. RESULTS A total of 226 advanced EMS providers participated with a 85.4% (n = 193) completion rate, consisting of a 30.7% rural, 32.3% urban, and 37.0% suburban mix; 82.4% were paramedics and 72.5% had worked in EMS >10 years. Only 57 (29.5%) participants scored both of the duplicate scenarios correctly, and only 19 of the 193 (9.8%) responded to all scenarios correctly. Level of training was not a predictor of correctly scoring scenarios (P = .71, RR = 1.25, 95% CI = 0.39-4.01), nor was years of service (P = .11, RR = 1.64, 95% CI = 0.16-1.21). CONCLUSIONS Poor understanding of the principles of diagnosis and management of sepsis was observed in this cohort, suggesting the need for enhancement of education. Survey items will be used to develop a focused, interactive Web-based learning program. Limitations include potential for self-selection and data accuracy.

Twenty-five years of violence: the epidemiology of terrorism in South America.

INTRODUCTION Terrorism is a global public health burden. South Americans have been victims of terrorism for many decades. While the causes vary, the results are the same: death, disability, and suffering. The objective of this study was to perform a comprehensive, epidemiological, descriptive study of terrorist incidents in South America. METHODS This is a cross-sectional, descriptive study. Data from January 1971 to July 2006 was selected using the RAND Terrorism Chronology 1968-1997 and RAND-Memorial Institute for Prevention of Terrorism (MIPT) Terrorism Incident database (1998-Present). Statistical significance was set at 0.05. RESULTS The database reported a total of 2,997 incidents in South American countries that resulted in 3,435 victims with injuries (1.15 per incident) and 1,973 fatalities (0.66 per incident). The overall case fatality ratio (CFR) was 35.8%. Colombia had the majority of incidents with 57.9% (1,734 of 2,997), followed by Peru with 363 (12.1%), and Argentina with 267 (8.9%). The highest individual CFR occurred in Paraguay (83.3%), and the lowest in Chile with 4.8%. Of the total injuries and deaths, Colombia had 66.1% (2,269 of 2,997) of all injuries and 75.2% (1,443 out of 1,920) of all deaths. Living in the country of Colombia was associated with a 16 times greater likelihood of becoming a victim of terrorist violence [odds ratio (OR) 16.15; 95% CI 13.45 to 19.40; p < 0.0001]. The predominant method of choice for terrorist incidents was the use of conventional explosives with 2,543 of2,883 incidents (88.2%). CONCLUSIONS Terrorist incidents in South America have accounted for nearly 2,000 deaths, with conventional explosive devices as the predominant method of choice. Understanding the nature of terrorist attacks and the medical consequences assist emergency preparedness and disaster management officials in allocating resources and preparing for potential future events.

Prognostic utility of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI)

BackgroundWe sought to evaluate the test characteristics of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) in relation to 30-day major adverse cardiac events (MACE) among patients who presented to the Emergency Department with symptoms suggestive of an acute coronary syndrome. We then examined the test characteristics of various dichotomous ACI-TIPI cut points.MethodsWe prospectively recruited a cohort of Emergency Department (ED) patients with acute chest pain at two urban university hospitals between June and September 2006. Upon enrollment, baseline demographics and cardiac risk factors were collected. An electrocardiogram (ECG) was performed and analyzed with the built-in ACI-TIPI multiple regression model software. An ACI-TIPI probability score was recorded for each patient. Diagnostic test characteristics of ACI-TIPI for MACE (non-ST elevation myocardial infarction (NSTEMI), percutaneous coronary intervention, coronary artery bypass grafting, and all-cause mortality) within 30 days were determined.ResultsOf 144 patients enrolled (mean age 59.1 ± 14.1 years, 59% men), 19 (13%) patients suffered MACE within 30 days. Receiver-operating characteristics (ROC) for ACI-TIPI yielded a c-statistic of 0.69 (95% CI 0.59-0.80, p < 0.01). An ACI-TIPI score of ≥ 20 had 100% sensitivity (95% CI 82-100), 100% negative predictive value (95% CI 86-100), and 21% specificity (14-31%).ConclusionsThese preliminary results suggest that, while ACI-TIPI has limited discriminatory value for MACE overall, a score of < 20 may have 30-day prognostic utility to allow for safe outpatient management in patients with acute chest pain.

Weapons of mass destruction preparedness and response for the XIV Pan-American Games, Santo Domingo, 2003

The Pan-American Games are considered to be the fourth most important international athletic event in the world. Hosted by the city of Santo Domingo, Dominican Republic, the XIV Pan-American Games lasted from 11-17 August 2003. In preparation for the Games, the Security Directorate developed and deployed a Weapons of Mass Destruction (WMD) Unit. For operational support, two strike teams (Alpha and Bravo) were active at any given time. Each team consisted of five members including a team leader, field physician, explosive ordinance disposal (EOD) officer, and two tactical officers. Three hospitals-two military and one civilian--were designated as primary medical centers for the event. With the assistance of the WMD Unit, emergency department staff were trained in the medical management of a WMD event, response protocols for WMD were created, and special decontamination areas were designated. Syndromic surveillance was performed by means of direct communications between the hospitals and units, as well as use of an electronic, Web-based surveillance tool.

Predictive effect of the injury severity score on the development of multiple organ failure among young adults and elderly patients

Study objectives: Multiple organ failure is a major cause of mortality in the injured patient, representing a significant financial burden to the health care system. Recent studies have demonstrated the importance of early prediction and early resuscitation for multiple organ failure to improve outcome. The objective of this study is to determine the correlation between Injury Severity Score (ISS) and multiple organ failure among severely injured young (aged 18 to 54 years) and elderly (aged 55 years) patients. Methods: This was a cross-sectional observational study from a hospital-based trauma registry. Data from 1997 were collected. All adult cases (>18 years) with acute trauma as defined by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes were included. Descriptive statistics were used to present group characteristics. For significance testing, χ 2 and Fishers exact test were used for categorical variables. Severe injuries were defined by an ISS greater than 15. Presence of multiple organ failure was based on the definitions proposed by Knaus and Fry. Results: Six hundred forty-two adult trauma patients were included, with 469 classified as young and 173 as elderly. Among the 469 young adults, 193 had ISS greater than 15 (41.2%), and 35 of these developed multiple organ failure (35 of 193, or 18.1%). Among the 173 elderly patients, 88 had an ISS greater than 15 (50.9%), and 51 met the definition for multiple organ failure (51 of 173, or 29.5%). Severely injured (ISS >15) young and elderly groups were more likely to develop multiple organ failure compared with those with an ISS less than 15 ( P P P Conclusion: This study demonstrated a direct relationship between ISS greater than 15 and the development of multiple organ failure. We also observed a fivefold increase in the development of multiple organ failure among severely injured elderly patients. Future studies should focus on early resuscitative interventions based on prompt emergency department severity estimates calculated from anatomic and physiologic scoring systems. Limitations of this study are primarily related to the retrospective data collection process and the subsequent accuracy of the medical records.