Won Chul Cha

Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study.

OBJECTIVES The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma. METHODS This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules. RESULTS A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to 48.5%). The sensitivity and specificity for neurosurgical intervention were as follows: CCHR, 100% (95% CI = 59.0% to 100.0%) and 38.3% (95% CI = 34.5% to 41.9%); NOC, 100% (95% CI = 54.1% to 100.0%) and 20.4% (95% CI = 17.4% to 23.7%); and NEXUS-II, 95.1% (95% CI = 90.1% to 98.0%) and 41.4% (95% CI = 39.5% to 43.2%). Among the enrolled population, intersection patients of CCHR, NOC, and NEXUS-II totaled 588. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 73 of 98 (74.5%, 95% CI = 64.7% to 82.8%) and 201 of 490 (41.0%, 95% CI = 36.6% to 45.5%); NOC, 89 of 98 (90.8%, 95% CI = 83.3% to 95.7%) and 112 of 490 (22.9%, 95% CI = 19.2% to 26.8%); and NEXUS-II, 82 of 98 (83.7%, 95% CI = 74.8% to 90.4%) and 172 of 490 (35.1%, 95% CI = 30.9% to 39.5%). The potential reduction in emergency CT scans by using these decision rules would have been higher with the NEXUS-II rule (39.6%, 95% CI = 37.8% to 41.4%) than with the CCHR rule (27.0%, 95% CI = 23.7% to 30.3%) or NOC rule (20.2%, 95% CI = 17.2% to 23.3%). CONCLUSIONS For clinically important TBI, the three cranial CT decision rules had much lower sensitivities in this population than the original published studies, while the specificities were comparable to those studies. The sensitivities for neurosurgical intervention, however, were comparable to the original studies. The NEXUS-II rule showed the highest reduction rate for CT scans compared to other rules, but failed to identify all undergoing neurosurgical intervention for their original inclusion cohort.

A point-of-care chemistry test for reduction of turnaround and clinical decision time

PURPOSE Our study compared clinical decision time between patients managed with a point-of-care chemistry test (POCT) and patients managed with the traditional central laboratory test (CLT). BASIC PROCEDURE This was a randomized controlled multicenter trial in the emergency departments (EDs) of 5 academic teaching hospitals. We randomly assigned patients to POCT or CLT stratified by the Emergency Severity Index. A POCT chemistry analyzer (Piccolo; Abaxis, Inc, Union City, Calif), which is able to test liver panel, renal panel, pancreas enzymes, lipid panel, electrolytes, and blood gases, was set up in each ED. Primary and secondary end point was turnaround time and door-to-clinical-decision time. MAIN FINDINGS The total 2323 patients were randomly assigned to the POCT group (n = 1167) or to the CLT group (n = 1156). All of the basic characteristics were similar in the 2 groups. The turnaround time (median, interquartile range [IQR]) of the POCT group was shorter than that of the CLT group (14, 12-19 versus 55, 45-69 minutes; P < .0001). The median (IQR) door-to-clinical-decision time was also shorter in the POCT compared with the CLT group (46, 33-61 versus 86, 68-107 minutes; P < .0001). The proportion of patients who had new decisions within 60 minutes was 72.8% for the POCT group and 12.5% for the CLT group (P < .0001). CONCLUSIONS A POCT chemistry analyzer in the ED shortens the test turnaround and ED clinical decision times compared with CLT.

Impact of Metformin Use on Lactate Kinetics in Patients with Severe Sepsis and Septic Shock.

Background: We aimed to evaluate the impact of metformin use on lactate kinetics in patients with severe sepsis and septic shock. Methods: We analyzed data from a registry that included patients who presented to the emergency department and met criteria for severe sepsis or septic shock. Patients were divided into two groups based on metformin use. We compared lactate concentrations, lactate clearance (LC), and normalization at 6 h (H6) and 24 h (H24) after the initial (H0) measurement. Propensity score matching, multiple logistic, and linear regression analysis via a generalized estimating equations method were used. Results: Of 1,318 patients, 71 patients were in the metformin use group and all 71 were selected in a one to two propensity matching. Metformin users showed significantly higher lactate levels at H0 (5.3 vs. 4.4 mmol/L) and H6 (3.8 vs. 2.9 mmol/L) in all patients, although in the matched subset, the effect was marginal (H0, 5.3 vs. 4.9 mmol/L; H6, 3.8 vs. 3.2 mmol/L; H24, 2.7 vs. 2.4 mmol/L). Mean LC (H6, 29% vs. 34%; H24, 43% vs. 49%) and normalization rate (H6, 27% vs. 28%; H24, 49% vs. 52%) were also not significantly different. Although metformin use appeared to be associated with higher lactate levels before using the propensity score method, no significant association was found between metformin use and lactate kinetics variables in the balanced matched subset data. Conclusions: Lactate levels in metformin users were initially elevated in the early phase of resuscitation from severe sepsis and septic shock. However, there was no significant difference in lactate levels, LC, and normalization over the initial 24 h period based on metformin use.

The Prevalence and Clinical Significance of Low Procalcitonin Levels Among Patients With Severe Sepsis or Septic Shock in the Emergency Department.

Background: The aims of this study were to evaluate the prevalence of low procalcitonin (PCT) levels among patients with severe sepsis or septic shock, and to investigate clinical characteristics and outcomes associated with low PCT levels. Methods: We analyzed data from the sepsis registry for patients with severe sepsis or septic shock in the emergency department. Based on a specific PCT cutoff value, patients were classified into two groups: a low PCT group, PCT <0.25 ng/mL; and a high PCT group, PCT ≥0.25 ng/mL. The primary endpoint was 28-day mortality. A multivariable logistic regression model was used to evaluate independent factors associated with low PCT and 28-day mortality. Results: A total of 1,212 patients were included. Of the eligible patients, 154 (12.7%) were assigned to the low PCT group, and 1,058 (87.3%) to the high PCT group. The 28-day mortality was 4.6% in the low PCT group and 13.5% in the high PCT group (P < 0.01). The adjusted odds ratio of the low PCT group for 28-day mortality was 0.43 (95% CI 0.19–0.98; P = 0.04). There was no trend of increasing mortality among higher PCT level patients. In a logistic regression model, factors associated with low PCT were pneumonia, lower C-reactive protein levels, lower lactate levels, the absence of bacteremia, and the absence of organ failure. Intra-abdominal infection and obesity were associated with high PCT. Conclusion: Initial low PCT levels were common among patients diagnosed with severe sepsis or septic shock in the emergency department, suggesting favorable outcomes. The prevalence of low PCT levels was significantly different according to obesity, the source of infection, C-reactive protein levels, lactate levels, bacteremia, and organ failure.

Effectiveness of Near-field Communication Integrated with Mobile Electronic Medical Record System in Terms of Physician Turn-around Time in an Emergency Department: Simulation Study (Preprint)

Background Improved medical practice efficiency has been demonstrated by physicians using mobile device (mobile phones, tablets) electronic medical record (EMR) systems. However, the quantitative effects of these systems have not been adequately measured. Objective This study aimed to determine the effectiveness of near-field communication (NFC) integrated with a mobile EMR system regarding physician turnaround time in a hospital emergency department (ED). Methods A simulation study was performed in a hospital ED. Twenty-five physicians working in the ED participated in 2 scenarios, using either a mobile device or personal computer (PC). Scenario A involved randomly locating designated patients in the ED. Scenario B consisted of accessing laboratory results of an ED patient at the bedside. After completing the scenarios, participants responded to 10 questions that were scored using a system usability scale (SUS). The primary metric was the turnaround time for each scenario. The secondary metric was the usability of the system, graded by the study participants. Results Locating patients from the ED entrance took a mean of 93.0 seconds (SD 34.4) using the mobile scenario. In contrast, it only required a mean of 57.3 seconds (SD 10.5) using the PC scenario (P<.001). Searching for laboratory results of the patients at the bedside required a mean of only 25.2 seconds (SD 5.3) with the mobile scenario, and a mean of 61.5 seconds (SD 11.6) using the PC scenario (P<.001). Sensitivity analysis comparing only the time for login and accessing the relevant information also determined mobile devices to be significantly faster. The mean SUS score of NFC-mobile EMR was 71.90 points. Conclusions NFC integrated with mobile EMR provided for a more efficient physician practice with good usability.

Protective effects of helmets on bicycle-related injuries in elderly individuals

Objective The increasing frequency of bicycle-related injuries is due to the growing elderly population and their increasing physical activity. This study aimed to compare the protective effects of helmets on bicycle-related injuries in elderly individuals compared with those in younger adults. Methods Data from the Korean emergency department–based Injury In-depth Surveillance database from eight emergency departments during 2011–2016 were retrospectively analysed. The subjects sustained injuries while riding bicycles. Cases with unknown clinical outcomes were excluded. Covariates included mechanism, place and time of injury. The primary outcome was traumatic brain injury (TBI) incidence, and the secondary outcomes were in-hospital mortality and severe trauma. The effects of helmets on these outcomes were analysed and differences in effects were determined using logistic regression analysis. Subsequently, the differences in the effects of helmets use between age groups were examined by using interaction analysis Results Of 7181 adults, 1253 were aged >65 years. The injury incidents showed a bimodal pattern with peaks around ages 20 and 50 years. Meanwhile, the helmet-wearing rate showed a unimodal pattern with its peak at age 35–40 years; it decreased consistently with age. By multivariate analysis, helmet-wearing was associated with a reduced TBI incidence (OR 0.76; 95% CI 0.57 to 0.99) and severe trauma (OR 0.78; 95% CI 0.65 to 0.93). The effects of helmets increased in elderly individuals (TBI (p=0.022) and severe trauma (p=0.024)). Conclusion The protective effects of helmets on bicycle-related injuries are greater for elderly individuals, thus reducing TBI incidence.

Coronary angiography is related to improved clinical outcome of out-of-hospital cardiac arrest with initial non-shockable rhythm

Objective Coronary angiography (CAG) for survivors of out-of-hospital cardiac arrest (OHCA) enables early identification of coronary artery disease and revascularization, which might improve clinical outcome. However, little is known for the role of CAG in patients with initial non-shockable cardiac rhythm. Methods We investigated clinical outcomes of successfully resuscitated 670 adult OHCA patients who were transferred to 27 hospitals in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a Korean nationwide multicenter registry. The primary outcome was 30-day survival with good neurological outcome. Propensity score matching and inverse probability of treatment weighting analyses were performed to account for indication bias. Results A total of 401 (60%) patients showed initial non-shockable rhythm. CAG was performed only in 13% of patients with non-shockable rhythm (53 out of 401 patients), whereas more than half of patients with shockable rhythm (149 out of 269 patients, 55%). Clinical outcome of patients who underwent CAG was superior to patients without CAG in both non-shockable (hazard ratio (HR) = 3.6, 95% confidence interval (CI) = 2.5–5.2) and shockable rhythm (HR = 3.7, 95% CI = 2.5–5.4, p < 0.001, all). Further analysis after propensity score matching or inverse probability of treatment weighting showed consistent findings (HR ranged from 2.0 to 3.2, p < 0.001, all). Conclusions Performing CAG was related to better survival with good neurological outcome of OHCA patients with initial non-shockable rhythms as well as shockable rhythms.

AP028 The impact of delayed transfer to inpatient units for successfully resuscitated out-of-hospital cardiac arrest patients on survival to discharge

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.