Shahriar Zehtabchi

The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs

OBJECTIVES Early recognition and treatment of hemorrhagic shock after trauma limits multi-organ failure and mortality. Traditional vital signs (VS) although specific are not highly sensitive for hemorrhage detection. Metabolic parameters such as lactate and base deficit (BD) are highly sensitive indicators of blood loss by measuring tissue perfusion. Does adding information from BD and lactate to traditional VS improve the identification of trauma patients with major injuries? METHODS We conducted a retrospective study of a prospectively collected database at a Level I trauma center from January 2003 to September 2005. Patients >13 years, suspected of having significant injury by mechanism, were included. Abnormal VS were defined by heart rate >100 beats/min or systolic blood pressure <90 mmHg. Metabolic parameters from initial arterial blood gas were measured in all patients, abnormal defined by BD >-2.0 mMol/L or lactate >2.2 mMol/L. Our outcome variable, major injury, was defined as any trauma patient who received a blood transfusion, or dropped their hematocrit >10 points in the first 24 h, or had an Injury Severity Score (ISS) >15. RESULTS 1435 patients were enrolled, 242 (17%) had major injuries. Abnormal VS alone had a sensitivity of 40.9% (95% CI, 34.7-47.1%) for identifying major injury patients. When abnormal metabolic parameters were added, major injury detection increased significantly to a sensitivity of 76.4% (95% CI, 71.1-81.8%). CONCLUSIONS The addition of BD and lactate to triage vital signs increases the ability to distinguish major from minor injury.

Management of Emergency Department Patients With Primary Spontaneous Pneumothorax: Needle Aspiration or Tube Thoracostomy?

STUDY OBJECTIVE The emergency management of primary spontaneous pneumothorax is controversial. This evidence-based emergency medicine review evaluates the existing evidence about the efficacy and safety of needle aspiration in comparison to tube thoracostomy for management of primary spontaneous pneumothorax. METHODS We searched MEDLINE, EMBASE, the Cochrane Library, and other databases. We selected studies for inclusion in the review if the authors stated that they had randomly assigned hemodynamically stable patients with no underlying lung disease to needle aspiration or tube thoracostomy. The outcome measures of interest included admission rate, length of hospital stay, recurrence rate, failure rate of the procedure, dyspnea score during or after the procedure, pain score during or after the procedure, and complications. RESULTS Three randomized trials with acceptable quality standards met the inclusion criteria. There was no significant difference between needle aspiration and tube thoracostomy when outcomes of immediate failure, 1-week failure, risk of complication, and 1-year recurrence rate were measured. Only 2 trials reported the rate of hospitalization; needle aspiration was associated with lower rates of hospitalization in both trials: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74). Length of hospital stay was lower in the needle aspiration groups in all 3 trials, with mean differences of -2.15 days (95% CI -0.99 to -3.30), -2.10 days (95% CI -0.57 to -3.63), and -1.10 days (95% CI -2.28 to 0.08), respectively. Needle aspiration was associated with less analgesia requirement in one trial and lower pain scores in another. CONCLUSION The existing evidence indicates that needle aspiration is at least as safe and effective as tube thoracostomy for management of primary spontaneous pneumothorax. Additionally, needle aspiration carries the benefit of fewer hospital admissions and shorter length of hospital stay.

Impact of Transfusion of Fresh‐frozen Plasma and Packed Red Blood Cells in a 1:1 Ratio on Survival of Emergency Department Patients with Severe Trauma

OBJECTIVES Coagulopathy is common after severe trauma and occurs very early after the initial insult. Some investigators have suggested early and aggressive treatment of the trauma-induced coagulopathy by transfusion of fresh-frozen plasma (FFP) and packed red blood cells (PRBC) in a 1:1 ratio. This evidence-based emergency medicine (EBM) review evaluates the evidence regarding the impact of 1:1 ratio of FFP:PRBC transfusion on survival of emergency department (ED) patients with severe trauma. METHODS The MEDLINE, EMBASE, Cochrane Library, and other databases were searched. Studies were selected for inclusion if they included trauma patients who required blood transfusion. The outcome measures of interest included mortality and adverse effects of high FFP:PRBC ratios. For comparison, the patients were classified into high ratio (1:1, defined as a ratio of 1:< or =1.5) and low ratio (1:>1.5) groups. RESULTS The authors did not identify any randomized controlled trials (RCT), but included four observational studies (three retrospective registry and one prospective cohort studies), which enrolled 1,511 patients cumulatively. One study found a statistically significant difference in mortality rate, favoring high FFP:PRBC ratio (relative risk = 0.72, 95% confidence interval [CI] = 0.59 to 0.89), while three studies showed no benefits. One study reported higher rates of sepsis and single/multiorgan failure (MOF), and another study revealed a higher risk of nosocomial infections and acute respiratory distress syndrome (ARDS) in the high FFP:PRBC ratio group. CONCLUSION Three retrospective registry reviews with suboptimal methodologies and one prospective cohort study provide inadequate evidence to support or refute the use of a high FFP:PRBC ratio in patients with severe trauma.

Trauma Registries: History, Logistics, Limitations, and Contributions to Emergency Medicine Research

Trauma registries have been designed to serve a number of purposes, including quality improvement, injury prevention, clinical research, and policy development. Since their inception over 30 years ago, there are increasingly more institutions with trauma registries, many of which submit data to a national trauma registry. The goal of this review is to describe the history, logistics, and characteristics of trauma registries and their contribution to emergency medicine and trauma research. Discussed in this review are the limitations of trauma registries, such as variability in quality and type of the collected data, absence of data pertaining to long-term and functional outcomes, prehospital information, and complications as well as other methodologic obstacles limiting the utility of registry data in clinical and epidemiologic research.

Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review

STUDY OBJECTIVE Omitting inpatient therapy for emergency department patients with newly diagnosed pulmonary embolism occurs infrequently in the United States. We seek to describe the safety of initial outpatient management of these patients and their demographics, comorbidities, risk stratification, treatment, and outcomes. METHODS We identified studies from searches of MEDLINE, EMBASE, and other databases from inception through March 22, 2012. We supplemented this with a search of conference proceedings and consultation with experts. We selected prospective studies of adults with acute, symptomatic, objectively confirmed pulmonary embolism who were discharged home without hospitalization. All contributing studies explicitly defined inclusion and exclusion criteria plus objectively confirmed outcome measures: recurrent thromboembolism, major hemorrhage, and mortality. Two investigators independently identified eligible studies and extracted data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to assess study quality. RESULTS From 2,286 screened titles/abstracts, we selected 8 studies with a total of 777 patients. Seven observational studies were rated low in quality. The one randomized controlled trial was higher in quality, used stricter inclusion criteria, and found that 90-day outcomes for outpatient management were not inferior to inpatient care. Among the 7 studies that reported 90-day outcome measures, the overall incidence of venous thromboembolic-related and hemorrhage-related mortality was very low: 0 of 741 (upper 95% confidence limit 0.62%). CONCLUSION The data on exclusive outpatient management of acute symptomatic pulmonary embolism are limited, but the existing evidence supports the feasibility and safety of this approach in carefully selected low-risk patients.

Management of traumatic occult pneumothorax

STUDY OBJECTIVE Occult pneumothorax (OPTX) is defined as a pneumothorax seen on computed tomography but not apparent on supine plain radiography. Though increasingly common, the acute management of OPTX after trauma remains controversial. This evidence-based review evaluates the existing evidence regarding the safety and efficacy of observation as compared to tube thoracostomy (TT) for management of OPTX in emergency department trauma patients. METHODS The authors searched MEDLINE, EMBASE, the Cochrane Library, and other databases. INCLUSION CRITERIA studies of adult or pediatric trauma victims at first presentation after blunt or penetrating injury (population), randomized to observation (intervention) or TT (comparison). Studies that enrolled patients on positive pressure ventilation were included but those that enrolled hemodynamically unstable patients were excluded. Outcomes of interest included progression of OPTX, mortality, complications (pneumonia, empyema), and length of stay in hospital and intensive care unit (ICU). RESULTS A total of 411 articles were identified. After applying the inclusion/exclusion criteria, 3 randomized trials enrolling a total of 101 patients were found to have acceptable quality standards suitable for analysis. The included studies did not reveal any significant difference between observation and TT in regards to progression of OPTX, risk of pneumonia, or length of stay in hospital or ICU. Mortality risk and empyema rate were also not different in the single studies that reported those outcomes. CONCLUSION The existing evidence leads to the conclusion that observation is at least as safe and effective as tube thoracostomy for management of occult pneumothorax.

Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

OBJECTIVES The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding? METHODS MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies. RESULTS Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%). CONCLUSIONS Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis.

Does Ethanol Explain the Acidosis Commonly Seen in Ethanol-Intoxicated Patients?

Objective. Emergency physicians frequently treat ethanol-intoxicated trauma patients. In patients with apparently minor injuries, the presence of metabolic acidosis is often attributed to serum ethanol. We tested whether there is justification for the bias that ethanol reliably explains the acidosis commonly seen in alcohol-intoxicated patients. Methods. Prospective, observational. Inclusion criteria: Ethanol-intoxicated patients admitted to the emergency department (ED) following significant trauma mechanisms, in whom diagnostic evaluation revealed only minor injury. Exclusion criteria: Major trauma (blood transfusions, drop in Hct > 10 points over 24 h, or Injury Severity Score [ISS] > 5) or positive urine toxicology screen. Definitions: Ethanol Intoxication: (Blood Alcohol Level (BAL) ≥ 80 mg/dl), Acidosis: BD ≤ − 3.0 mMol/L; Lactic Acidosis (LAC > 2.2 mMol/L). Data were reported as mean ± SD. Data were compared by t-tests or Fishers exact test as appropriate (α = 0.05, 2 tails) and correlations by Pearson correlation coefficient. Results. 192 patients were studied (84% male) with a mean age of 31.7 ± 15.6 years. Acidosis was observed in 19.3% (CI 95%, 14.5% to 25.0%) of all study patients. We observed significant (p < 0.001) difference in prevalence of acidosis in ethanol intoxicated (42%) compared to nonintoxicated (1%) patients. Comparing the two study groups, patients with ethanol intoxication had lower BD ( − 2.24 ± 2.74 vs. − 0.05 ± 2.35, p < 0.001) and higher LAC (2.69 ± 1.48 vs. 2.00 ± 1.78, p = 0.02). However, ethanol levels did not correlate significantly with BD (p = 0.50) or LAC (p = 0.14). Conclusion. Ethanol intoxication is associated with acidosis, which does not correlate with BD or LAC. The complexity of pathogenesis of acidosis in ethanol intoxication justifies further diagnostic evaluation of these patients in order to rule out other causes of acidosis.

Silver sulfadiazine for the treatment of partial-thickness burns and venous stasis ulcers

BACKGROUND For decades silver-containing antibiotics such as silver sulfadiazine (SSD) have been applied as standard topical therapy for patients with partial-thickness burns and venous stasis ulcers. This evidence-based review intends to answer the following research question: in ambulatory patients with partial-thickness burns or stasis dermatitis ulcers, does the use of topical SSD compared with nonantibiotic dressings improve mortality, wound healing, re-epithelialization, or infection rates? METHODS MEDLINE, EMBASE, Cochrane Library, and other databases were searched. We considered trials that enrolled patients of any age with partial-thickness burns or venous stasis ulcers and randomized them to either topical SSD or placebo, saline-soaked gauze, paraffin gauze, sterile dry dressing, or nonantibiotic moist dressing. Outcomes included mortality, wound healing, speed of re-epithelialization, and infection rates. RESULTS For burns, our search revealed 400 potential articles. No human studies met the inclusion criteria. Only 7 animal studies (1 mouse, 4 rat, and 2 pig) were relevant to the proposed question. These animal studies provided conflicting results. Whereas some support the use of SSD for treatment of partial-thickness burns, others question its effectiveness. For stasis dermatitis ulcer, the search identified 50 articles for review, of which 20 abstracts were reviewed, and one article met the inclusion criteria. This study did not show any significant improvement in the rate of complete healing in SSD group compared with placebo either at 4 weeks (relative risk 6.2, 95% confidence interval 0.8-48) or at 1 year (relative risk 5.2, 95% confidence interval 0.6-41.6) of follow-up. CONCLUSION There is insufficient evidence to either support or refute the routine use of SSD for ambulatory patients with either partial-thickness burns or stasis dermatitis ulcers to decrease mortality, prevent infection, or augment wound healing in human beings.

A structured approach to transforming a large public hospital emergency department via lean methodologies.

&NA; Emergency Departments (EDs) face significant challenges in providing efficient, quality, safe, cost‐effective care. Lean methodologies are a proposed framework to redesign ED practices and processes to meet these challenges. We outline a systematic way that lean principles can be applied across the entire ED patient experience to transform a high volume ED in a safety net hospital. We review the change in ED performance metrics prior to and after lean implementation. We discuss critical insights and key lessons learned from our lean transformation to date. The steps to implementing lean principles across the patients ED experience are described with specific attention to executive planning of rapid improvement experiments and the subsequent roll‐out of lean transformation over an 18‐month time frame. Basic ED performance data were compared to the year prior. Results of the exploratory analysis (using median and interquartile ranges and nonparametric tests for group comparisons) have shown improvement in several performance metrics after initiating lean transformation. The approach, lessons learned, and early data of our transformation can provide critical insights for EDs seeking to incorporate continuous improvement strategies. Key lessons and unique challenges encountered in safety net hospitals are discussed.