Nicholas D. Caputo

Triage vital signs do not correlate with serum lactate or base deficit, and are less predictive of operative intervention in penetrating trauma patients: a prospective cohort study

Background Triage vital signs are often used to help determine a trauma patients haemodynamic status. Recent studies have demonstrated that these may not be very specific in determining major injury. The purpose of this study was to determine if there is any correlation between triage vital signs, base deficit (BD) and lactate, and to determine the odds of operative intervention in penetrating trauma patients. Methods A prospective observational cohort study was undertaken. Baseline vital signs, BD and lactate were recorded in all patients for whom the trauma team was activated. Pearson correlation and coefficient (ρ) were calculated. ORs were calculated. Results 75 patients were enrolled. Pearson correlations and coefficients calculated for lactate to systolic blood pressure were: −0.052 (ρ=0.0011, 95% CI −0.225 to 0.228); lactate and HR: 0.23 (ρ=0.0166, 95% CI −0.211 to 0.242); lactate and RR: 0.23 (ρ=0.054, 95% CI −0.174 to 0.277). BD to systolic blood pressure were: 0.003 (ρ=0.00001, 95% CI −0.229 to 0.224); BD and HR: −0.19 (ρ=0.038, 95% CI −0.399 to 0.038); BD and RR: −0.019 (ρ=0.0004, 95% CI −0.244 to 0.208). Odds of operative intervention were greater in patients with abnormally high lactate, OR 4.17 (95% CI 1.57 to 11), but not for BD, OR 2.53 (95% CI 0.99 to 6.45), or any of the vital signs. Conclusions Triage vital signs have no correlation to lactate or BD levels in penetrating trauma patients. Odds of operative intervention are greater in patients with abnormally high serum lactate levels, but not in those with abnormal triage vital signs or BD.

Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate?

Objective The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physicians perception of desaturation events. Methods A timed, observation prospective cohort study was conducted. A post-intubation survey was administered to the intubating physician. Each step of the procedure was timed by an observer in order to determine actual TTI. The number of desaturation events was also recorded. Results One hundred individual intubations were included. The provider perceived TTI was significantly different and underestimated when compared with the actual TTI (23 s, 95% confidence interval (CI) 20.4–25.49 vs 45.5 s, 95% CI 40.2–50.7, P < 0.001, respectively). Pearson correlation coefficient of perceived TTI to actual TTI was r2 = 0.39 (95% CI 0.21–0.54, P < 0.001). The provider perceived desaturation rate was also significantly different from actual desaturation rate (13, 95% CI 3–12 vs 23, 95% CI 13–29, P = 0.05, respectively). The overall time to desaturation was 65.1 s. Conclusions Our findings have shown that providers perception of TTI occurs sooner than actually observed. Also, the providers were less aware of desaturation during the procedure.The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physicians perception of desaturation events.

A Sedentary Job? Measuring the Physical Activity of Emergency Medicine Residents

BACKGROUND The debate on the quality of health care provided in the United States has continued to be waged as concerns have grown over the years. Stress, sleep deprivation, poor diet, and lack of exercise may lead to inadequate work performance by physicians. OBJECTIVE This study was undertaken to determine whether Emergency Medicine (EM) residents satisfy daily recommendations for total number of steps taken per day set forth by the Centers for Disease Control and Prevention and Surgeon General in a 12-h shift. METHODS An observational prospective cohort study was conducted between August 2009 and November 2009 at an urban Level I trauma center with an annual census of over 165,000 Emergency Department (ED) visits per year. The mean number of steps taken by EM residents during 12-h shifts was measured. RESULTS Mean steps taken during a shift were 7333 (95% confidence interval 6901-7764). Only nine (9.9%) pedometer readings reached the target level of 10,000 (10 K) steps or above. A t-test was used to compare steps with the hypothesized 10 K steps target. Recordings of 10K steps or greater were not correlated with ED sections (p=0.60) shift (medical vs. surgical, p=0.65) or ED census (r(2)<0.0017). CONCLUSION A majority of residents (90%) did not meet the target number of steps for shifts. More rigorous charting needs, overcrowding, or even spatial limitations may explain this. This warrants further investigation to determine if some daily physical activity regimens may help improve the overall well-being of EM residents.

Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED

BACKGROUND Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) have been shown to be of use in determining shock in patients with seemingly normal vital signs. We seek to determine if these biomarkers can be used interchangeably in patients with trauma in the emergency setting based on their test characteristics and correlation to each other. METHODS A prospective observational cohort study was undertaken at an urban level 1 trauma center. Baseline vital signs, point-of-care BE, AG, and serum lactate were recorded in all patients who presented for trauma. Correlation was determined by linear regression model. Overall test characteristics and relative risk were calculated. RESULTS One hundred patients were enrolled. The median age was 30 years (interquartile range, 24-42 years), and 89% were male. Fifty-three percent of injuries were blunt trauma. Pearson correlation of serum lactate to BE was -0.81 (r(2) = 0.66; 95% confidence interval [CI], 0.53-0.75; P < .001), that of BE to AG was -0.71 (r(2) = 0.5; 95% CI, -0.80 to -0.57; P < .01), and that for serum lactate to AG was 0.71 (r(2) = 0.5; 95% CI, 0.57-0.80; P < .01). CONCLUSIONS This study demonstrates that the biomarkers have similar test characteristics which may make them interchangeable as indicators for the presence of occult shock in patients with trauma. Lactate and BE correlate well with each other; however, AG was not as strongly correlated with either.

Posterior reversible encephalopathy syndrome presenting as papilledema

Posterior reversible encephalopathy syndrome (PRES) is a central nervous system pathology characterized by headaches, altered mental status, seizures, and visual loss. The syndrome is a clincoradiologic diagnosis, which mandates neuroimaging. The aim of this study is to describe a case of asymptomatic PRES in which the only sign was incidental papilledema found on ophthalmologic examination. A thin 19-year-old female G1P1 s/p natural spontaneous vaginal delivery was referred to our emergency department (ED) by the ophthalmology clinic after finding bilateral papilledema on fundoscopic examination. She denied any fevers, chills, nausea, vomiting, as well as headache, lightheadedness, visual changes, or blurriness. Lumbar puncture was performed, and opening pressure was found to be greater than 55 cmH2O. After collecting Cerebrospinal fluid (CSF) for routine analysis, approximately 15 to 20 mL of CSF was drained. After several revisits to the ED, the neurology clinic was consulted. The magnetic resonance imaging ordered by the neurology clinic, as read by the radiologist, showed a focal lesion in splenium of the corpus callosum and diffusion restriction suggestive of acute infarction (although the anatomical location and age would be unusual). This is an atypical manifestation of PRES. The myriad of clinical symptoms and presentations of PRES has become more identifiable as more case reports of the syndrome are published. This case demonstrates that this atypical syndrome may present in an atypical way. The patient may be asymptomatic, and although imaging defines the diagnosis, a complete physical examination must not be ignored because the only sign may be papilledema.

Determining the Utility of Metabolic Acidosis for Trauma Patients in the Emergency Department

BACKGROUND Metabolic acidosis has been proposed as the gold standard to define shock in trauma patients. Other studies determine the presence of shock by use of serum lactate. However, not all medical centers have the ability to utilize point-of-care lactate at bedside. OBJECTIVE This study seeks to determine the relationship between serum lactate and metabolic acidemia in trauma patients, and if metabolic acidemia can be used to guide therapy. We hypothesized that acidemia would be strongly correlated with lactate levels and would be associated with activation of massive transfusion (MT) in the presence of shock in trauma. METHODS This was a prospective observational cohort study, level II evidence; this study aids in decision-making. Setting was a Level I academic, urban trauma center. The study took place from July 1, 2012 to March 1, 2013 and included patients who were ≥18 years old and required trauma team activation. Observations included baseline demographics (age, gender, type of injury), vital signs, point-of-care arterial blood gas, lactate, and need for MT. RESULTS One hundred patients were enrolled over the study period. The average age was 34 years, and 82% were male. Forty patients were acidemic (pH < 7.35), and there was a significant difference in lactate levels between the acidemic and non-acidemic groups (p < 0.002). We found a strong correlation between pH and lactate: rs = -0.38, t = -4.03, p < 0.001. In addition, using a logistic regression, we show that pH was associated with activation of MT (p = 0.002). CONCLUSION This is a prospective observational cohort study with level II evidence. This study demonstrates that acidemia was strongly correlated to serum lactate, lactate levels were higher in the acidemic group, and metabolic acidemia was associated with the activation of MT for trauma patients at our institution.

A retrospective analysis of the utility of an artificial neural network to predict ED volume.

OBJECTIVE The objectives of this study are to design an artificial neural network (ANN) and to test it retrospectively to determine if it may be used to predict emergency department (ED) volume. METHODS We conducted a retrospective review of patient registry data from February 4, 2007, to December 31, 2009, from an inner city, tertiary care hospital. We harvested data regarding weather, days of week, air quality, and special events to train the ANN. The ANN belongs to a class of neural networks called multilayer perceptrons. We designed an ANN composed of 37 input neurons, 22 hidden neurons, and 1 output neuron designed to predict the daily number of ED visits. The training method is a supervised backpropagation algorithm that uses mean squared error to minimize the average squared error between the ANNs output and the number of ED visits over all the example pairs. RESULTS A linear regression between the predicted and actual ED visits demonstrated an R2 of 0.957 with a slope of 0.997. Ninety-five percent of the time, the ANN was within 20 visits. CONCLUSION The results of this study show that a properly designed ANN is an effective tool that may be used to predict ED volume. The scatterplot demonstrates that the ANN is least predictive at the extreme ends of the spectrum suggesting that the ANN may be missing important variables. A properly calibrated ANN may have the potential to allow ED administrators to staff their units more appropriately in an effort to reduce patient wait times, decrease ED physician burnout rates, and increase the ability of caregivers to provide quality patient care. A prospective is needed to validate the utility of the ANN.

Re-Evaluating the Diagnostic Accuracy of the Tongue Blade Test: Still Useful as a Screening Tool for Mandibular Fractures?

BACKGROUND Mandibular fractures are one of the most frequently seen injuries in trauma. In terms of facial trauma, mandible fractures constitute 40%-62% of all facial bone fractures. The tongue blade test (TBT) has been shown to be a sensitive screening tool when compared with plain films. However, recent studies have demonstrated that computed tomography (CT) scan is more sensitive for determining mandible fractures than the traditionally used plain films. OBJECTIVE The purpose of the study was to determine the sensitivity and specificity of the TBT as compared with the new gold standard of radiologic imaging, CT scan. METHODS Any patient suffering from facial trauma was prospectively enrolled during the study period (August 1, 2010 to April 11, 2012) at a single urban, academic Emergency Department. A TBT was performed by the resident physician and confirmed by the supervising attending. CT facial bones were then obtained for the ultimate diagnosis. Inter-rater reliability (κ) was calculated, along with sensitivity, specificity, negative predictive value, and likelihood ratio (-) based on a 2 × 2 contingency table generated. RESULTS During the study period, 190 patients were enrolled. Inter-rater reliability was κ = 0.96 (95% confidence interval [CI] 0.93-0.99). The following parameters were then calculated based on the contingency table: sensitivity 0.95 (95% CI 0.88-0.98), specificity 0.68 (95% CI 0.57-0.77), negative predictive value 0.92 (95% CI 0.82-0.97), and likelihood ratio (-) 0.07 (95% CI 0.03-0.18). CONCLUSIONS Based on the test characteristics calculated (negative predictive value 0.92, sensitivity 0.95, likelihood ratio -0.07), the TBT is a useful screening tool to determine the need for radiologic imaging.

Imaging prevalence of nasal septal perforation in an urban population

OBJECTIVE To determine the prevalence of nasal septal perforation (NSP) on CT imaging in an urban hospital setting. METHODS Facial bone CT scans from 3708 consecutive patients were reviewed for the presence of NSP. Size of the perforation was measured in two dimensions. Medical records were reviewed for possible risk factors. RESULTS The prevalence of NSP was 2.05%. The most common risk factor was a history of drug abuse. Cocaine was the most prevalent drug used. CONCLUSION The prevalence of NSP was more than double of that previously published, likely related to intranasal drug use in our urban population.

Noninvasive ventilation during procedural sedation in the ED: a case series

Given this information, although the authors reported that 100% of patients had elevated CRP and the elevated CRP was used to rule in serositis, we propose that, in SLE, the CRP level is not as sensitive as it would appear here. Thus, the physicianmust be aware of this complex relationship, knowing that the predictive value of an elevated conventional CRP assay on SLE disease activity and cardiovascular risk is still limited at present. Secondly, we comment on the frequent occurrence of coexisting pericardial and pleural effusions in SLE disease presentation. This correlation was explained by the authors as a generalized serositis. In SLE, the pathogenesis of serositis is thought to involve immune complex deposition stimulating an inflammatory reaction [5]. Although this can simultaneously affect both the pleura and pericardium, we draw attention to the fact that outside of autoimmune serositis, there is a strong link between pericardial disease and pleural effusion, in particular, a predominantly left-sided effusion [6,7]. It would be interesting for the authors to have reported if the coexistent pleural effusions were predominantly left sided. This little-known association is clinically important for emergency physicians. The finding of increased transverse cardiac diameter and a left-sided pleural effusion on imaging should arouse suspicion of pericardial disease. This can be an early clue to a pericardial effusion, which can otherwise be silently progressing to tamponade physiology. Furthermore, this association is important to recognize as a small pericardial effusion in existence with a large pleural effusion can produce cardiac tamponade, which may actually resolve with pleural tap [8,9]. In conclusion, physicians must always consider SLE as a differential in patients presentingwith cardiac symptoms in the appropriate clinical context. This involves appropriate laboratory investigations, with cautious interpretation of CRP levels, and remembering the link between pericardial and pleural effusions when interpreting imaging and instituting management.