Jody A. Vogel

Levamisole-Induced Occlusive Necrotizing Vasculitis of the Ears After Use of Cocaine Contaminated with Levamisole

Based on the best available data, approximately 2.1 million Americans use illicit cocaine each month; for the last several months, 30% of that cocaine has been “cut” with a veterinary pharmaceutical, levamisole. Levamisole can cause agranulocytosis, leaving patients susceptible to fulminate and opportunistic infections and also can cause a debilitating cutaneous necrotizing vasculitis. In this manuscript, we describe a case and provide an image of levamisole-induced necrotizing vasculitis of the ears.

Prediction of postinjury multiple-organ failure in the emergency department: development of the Denver Emergency Department Trauma Organ Failure score.

BACKGROUND Multiple-organ failure (MOF) is common among the most seriously injured trauma patients. The ability to easily and accurately identify trauma patients in the emergency department at risk for MOF would be valuable. The aim of this study was to derive and internally validate an instrument to predict the development of MOF in adult trauma patients using clinical and laboratory data available in the emergency department. METHODS We enrolled consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry, a prospectively collected database from an urban Level 1 trauma center. Multivariable logistic regression was used to develop a clinical prediction instrument. The outcome was the development of MOF within 7 days of admission as defined by the Sequential Organ Failure Assessment (SOFA) score. A risk score was created from the final regression model by rounding the regression &bgr; coefficients to the nearest integer. Calibration and discrimination were assessed using 10-fold cross-validation. RESULTS A total of 4,355 patients were included in this study. The median age was 37 years (interquartile range [IQR], 26–51 years), and 72% were male. The median Injury Severity Score (ISS) was 9 (IQR, 4–16), and 78% of the patients had blunt injury mechanisms. MOF occurred in 216 patients (5%; 95% confidence interval, 4–6%). The final risk score included patient age, intubation, systolic blood pressure, hematocrit, blood urea nitrogen, and white blood cell count and ranged from 0 to 9. The prevalence of MOF increased in an approximate exponential fashion as the score increased. The model demonstrated excellent calibration and discrimination (calibration slope, 1.0; c statistic, 0.92). CONCLUSION We derived a simple, internally valid instrument to predict MOF in adults following trauma. The use of this score may allow early identification of patients at risk for MOF and result in more aggressive targeted resuscitation and improved resource allocation. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Dental pain as a risk factor for accidental acetaminophen overdose: a case-control study☆☆☆

UNLABELLED Patients frequent take acetaminophen to treat dental pain. One previous study found a high rate of overuse of nonprescription analgesics in an emergency dental clinic. OBJECTIVES The purpose of this study is to determine if patients with dental pain are more likely to be treated for accidental acetaminophen poisoning than patients with other types of pain. METHODS We conducted a case-control study at 2 urban hospitals. Cases were identified by chart review of patients who required treatment for accidental acetaminophen poisoning. Controls were self-reported acetaminophen users taking therapeutic doses identified during a survey of emergency department patients. For our primary analysis, the reason for taking acetaminophen was categorized as dental pain or not dental pain. Our primary outcome was the odds ratio of accidental overdose to therapeutic users after adjustment for age, sex, alcoholism, and use of combination products using logistic regression. RESULTS We identified 73 cases of accidental acetaminophen poisoning and 201 therapeutic users. Fourteen accidental overdose patients and 4 therapeutic users reported using acetaminophen for dental pain. The adjusted odds ratio for accidental overdose due to dental pain compared with other reasons for use was 12.8 (95% confidence interval, 4.2-47.6). CONCLUSIONS We found that patients with dental pain are at increased risk to accidentally overdose on acetaminophen compared with patients taking acetaminophen for other reasons. Emergency physicians should carefully question patients with dental pain about overuse of analgesics.

Patient‐centered outcomes research in emergency care: opportunities, challenges and future directions

The Patient-Centered Outcomes Research Institute (PCORI) was established by Congress in 2010 to promote the conduct of research that could better inform patients in making decisions that reflect their desired health outcomes. PCORI has established five national priorities for research around which specific funding opportunities are issued: 1) assessment of prevention, diagnosis, and treatment options; 2) improving healthcare systems; 3) communication and dissemination research; 4) addressing disparities; and 5) improving methods for conducting patient-centered outcomes research. To date, implementation of patient-centered research in the emergency care setting has been limited, in part because of perceived challenges in meeting PCORI priorities such as the need to focus on a specific disease state or to have planned follow up. We suggest that these same factors that have been seen as challenges to performing patient-centered research within the emergency setting are also potential strengths to be leveraged to conduct PCORI research. This paper explores factors unique to patient-centered emergency care research and highlights specific areas of potential alignment within each PCORI priority.

Emergency Department Visits by Older Adults for Motor Vehicle Collisions

Introduction: To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.). Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18–64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults. Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6–8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0–18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46–9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77–3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42–2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8–19.2) of older MVC patients and 6.1% (95% CI 4.8–7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71–4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9–51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury. Conclusion: Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, EDs will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

Study objective To identify critical emergency medicine–focused firearm injury research questions and develop an evidence‐based research agenda. Methods National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine–relevant research questions. In‐person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated. Results Fifty‐nine final emergency medicine–relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self‐directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional (“accidental”) injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings. Conclusion The technical advisory group identified key emergency medicine–relevant firearm injury research questions. Emergency medicine–specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Denver ED Trauma Organ Failure Score outperforms traditional methods of risk stratification in trauma

BACKGROUND Early identification of trauma patients at risk for inhospital mortality may facilitate goal-directed resuscitation and secondary triage to improve outcomes. The objective of this study was to compare prognostic accuracies of the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, ED Sequential Organ Failure Assessment (SOFA) score, and ED base deficit and ED lactate for inhospital mortality in adult trauma patients. METHODS Consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry were included. Prognostic accuracies of the Denver ED TOF Score, ED SOFA score, ED base deficit, and ED lactate for inhospital mortality were evaluated with receiver operating characteristic curves. RESULTS Of the 4355 patients, the median age was 37 years (interquartile range [IQR], 26-51 years), median Injury Severity Score was 9 (IQR, 4-16), and 81% had blunt mechanisms. In addition, 38% (1670 patients) were admitted to the intensive care unit with a median intensive care unit length of stay of 2.5 days (IQR, 1-8 days), and 3% (138 patients) died. The areas under the receiver operating characteristic curves for the Denver ED TOF, ED lactate, ED base deficit, and ED SOFA were 0.94 (95% confidence interval [CI], 0.94-0.96), 0.88 (95% CI, 0.85-0.91), 0.82 (95% CI, 0.78-0.86), and 0.78 (95% CI, 0.73-0.82), respectively. CONCLUSIONS The Denver ED TOF Score more accurately predicts inhospital mortality in adult trauma patients compared to the ED SOFA score, ED base deficit, or ED lactate. The Denver ED TOF Score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes.

Alcohol as a Factor in 911 Calls in Denver

Abstract Background: Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system. Objectives: The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs. Methods: This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data. Results: During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29–59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded

Denver Emergency Department Trauma Organ Failure Score predicts healthcare resource utilization in adult trauma patients

14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time. Conclusions: Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

Validation of Rules to Predict Emergent Surgical Intervention in Pediatric Trauma Patients

BACKGROUND Early identification of trauma patients who need specialized healthcare resources may facilitate goal-directed resuscitation and effective secondary triage. OBJECTIVE To estimate associations between Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score and healthcare resource utilization. METHODS Retrospective study of adult trauma patients at Denver Health Medical Center. The outcome was resource utilization including: intensive care unit (ICU) length of stay (LOS), hospital LOS, procedures, and costs. Multivariable regression analyses were used to estimate associations between moderate- or high-risk patients, as determined by the Denver ED TOF Score, and healthcare resource utilization. RESULTS We included 3000 patients with a median age of 42 (IQR 27-56) years, 71% male, median injury severity score 9 (IQR 5-16), and 83% blunt mechanism. Among the cohort, 1379 patients (46%) were admitted to the ICU and 122 (4%) died. The adjusted relative risk for high- and moderate-risk as compared to low risk for number of procedures performed was 2.31 (95% CI 2.07-2.57) and 1.80 (95% CI 1.59-2.03) respectively; ICU LOS was 2.87 (95% CI 2.70-3.05) and 1.71 (95% CI 1.60-1.83) respectively; hospital LOS was 3.33 (95% CI 3.21-3.45) and 1.97 (95% CI 1.90-2.05) respectively. The adjusted geometric mean for high-, moderate-, and low-risk for costs was