Zachary D.W. Dezman

Failure to Clear Elevated Lactate Predicts 24-Hour Mortality in Trauma Patients

BACKGROUND Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. METHODS A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts. RESULTS Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7] mmol/L) that normalized (1.4 [0.4] mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5–35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7–25.2). CONCLUSION Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients. LEVEL OF EVIDENCE Prognostic study, level III.

The Severity of Bleeding and Mortality in Trauma Patients Taking Dabigatran

BACKGROUND Dabigatran, a direct thrombin inhibitor, has been shown to be more effective than warfarin in the prevention of stroke in patients with atrial fibrillation. Until recently, it lacked a reversal agent, and its contribution to the risk of transfusion in injured patients is unknown. OBJECTIVE We sought to determine whether patients who sustain traumatic injuries while taking dabigatran receive more blood transfusions than matched patients taking warfarin, aspirin, clopidogrel, or controls. METHODS This retrospective, single-center cohort consisted of injured patients who were taking dabigatran before admission to a major trauma center (January 2010-December 2013) who were compared with cohorts of patients taking warfarin, clopidogrel, or aspirin and a control group. The outcome was bleeding risk as measured by the use of blood products, with mortality as a secondary outcome. Outcomes were controlled for by age, sex, injury severity, and blunt mechanism. RESULTS Thirty-eight patients were taking dabigatran. Compared with the general trauma population, patients taking dabigatran were more likely to be male, older, and to have higher injury severity. Patients taking dabigatran received transfusions (odds ratio [OR] 1.31 [95% confidence interval {CI} 0.56-3.04]), packed red blood cells (OR 1.43 [95% CI 0.54-3.77]), frozen plasma (OR 1.20 [95% CI 0.42-3.49]), and platelets (OR 2.01 [95% CI 0.63-6.37]) as often as matched controls. The mortality rate among patients on dabigatran was 12.5% (OR 1.51 [95% CI 0.39-5.89]) compared with 9.1% in matched controls. None of these results was statistically significant. CONCLUSIONS In this small study, injured patients taking dabigatran were transfused as often and had similar in-hospital mortality as matched controls who were not taking anticoagulants.

Alcohol consumption decreases lactate clearance in acutely injured patients

INTRODUCTION Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. METHODS We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1-Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). RESULTS Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. CONCLUSIONS In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.

The Decline in Hydrocodone/Acetaminophen Prescriptions in Emergency Departments in the Veterans Health Administration Between 2009 to 2015

Introduction The purpose of the study was to measure national prescribing patterns for hydrocodone/acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. Methods We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. Results During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=−0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192–3.205]), a musculoskeletal (OR 1.622, CI [1.615–1.630]) or soft tissue (OR 1.656, CI [1.649–1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271–1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833–1.853]). Conclusion Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal.

Hotspots and causes of motor vehicle crashes in Baltimore, Maryland: a geospatial analysis of five years of police crash and census data

INTRODUCTION Road traffic injuries are a leading killer of youth (aged 15-29) and are projected to be the 7th leading cause of death by 2030. To better understand road traffic crash locations and characteristics in the city of Baltimore, we used police and census data, to describe the epidemiology, hotspots, and modifiable risk factors involved to guide further interventions. MATERIALS AND METHODS Data on all crashes in Baltimore City from 2009 to 2013 were made available from the Maryland Automated Accident Reporting System. Socioeconomic data collected by the US CENSUS 2010 were obtained. A time series analysis was conducted using an ARIMA model. We analyzed the geographical distribution of traffic crashes and hotspots using exploratory spatial data analysis and spatial autocorrelation. Spatial regression was performed to evaluate the impact of socioeconomic indicators on hotspots. RESULTS In Baltimore City, between 2009 and 2013, there were a total of 100,110 crashes reported, with 1% of crashes considered severe. Of all crashes, 7% involved vulnerable road users and 12% had elderly or youth involvement. Reasons for crashes included: distracted driving (31%), speeding (6%), and alcohol or drug use (5%). After 2010, we observed an increasing trend in all crashes especially from March to June. Distracted driving then youth and elderly drivers were consistently the highest risk factors over time. Multivariate spatial regression model including socioeconomic indicators and controlling for age, gender and population size did not show a distinct predictor of crashes explaining only 20% of the road crash variability, indicating crashes are not geographically explained by socioeconomic indicators alone. CONCLUSION In Baltimore City, road traffic crashes occurred predominantly in the high density center of the city, involved distracted driving and extremes of age with an increase in crashes from March to June. There was no association between socioeconomic variables where crashes occurred and hotspots. In depth analysis of how modifiable risk factors are impacted by geospatial characteristics and the built environment is warranted in Baltimore to tailor interventions.

Young Woman With Chest Pain After Fall

An18-year-oldwomancame toour emergencydepartment (ED) for evaluationof central chest pain.Twodays earlier, shehadbeen tackled during a rugby tournament, falling on the point of her left shoulder. She was evaluated at another ED the day of the injury, where her chest radiograph was read as normal and she was sent home with a diagnosis of musculoskeletal pain. She came to our ED because the pain hadworsened, especially when shemoved her left arm. Shewas not experiencing dysphagia, dyspnea, or paresthesias. The patient was well-appearing but carried her left elbow in her right hand. Physical examination revealed a normal left shoulder with full range of motion, with no signs of trauma. She had reproducible central chest tenderness and loss of the prominence of the medial condyle of her left clavicle. She had full radial and ulnar pulses, and her breath sounds were normal bilaterally.Her examination result was otherwise normal. Radiographs of her chest, including a serendipity view,were obtained (Figures 1 and 2), as well as computed tomography (CT) of her chest (Figure 3).

Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients

Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the most common reason for emergency hospital admission. One of the most serious diagnoses emergency physicians must consider is acute coronary syndrome (ACS). This is both common and serious, as ischemic heart disease remains the single biggest cause of death in the western world. The history and physical examination are cornerstones of our diagnostic approach in this patient group. Their importance is emphasized in guidelines, but there is little evidence to support their supposed association. The purpose of this article was to summarize the findings of recent investigations regarding the ability of various components of the history and physical examination to identify which patients presenting to the ED with chest pain require further investigation for possible ACS. Previous studies have consistently identified a number of factors that increase the probability of ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, and diaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limited diagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with a non-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably by clinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to a generally acceptable level (<1%). Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS, while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible with ACS and an alternative cause cannot be identified, clinicians must strongly consider the need for further investigation with ECG and troponin measurement.

Purpura and leukopenia in a cocaine user.

Abstract A previously healthy 42-year-old woman presented to the emergency department (ED) for arthralgias and painful lesions on her ears, feet, and knee (Figures 1 and 2) that had developed over the last month. She had no significant past medical history and was not taking any prescribed medications. The rash was purpuric with violaceous borders and hemorrhagic bullae. While she had mild pain with movement, her joint examination was otherwise normal and without signs of infection. ED laboratory testing revealed leukopenia (2500/mm3) and cocaine metabolites in her urine.

Test characteristics of a drug CAGE questionnaire for the detection of non-alcohol substance use disorders in trauma inpatients

BACKGROUND Non-alcohol substance use disorders (drug use disorders [DUDs]) are common in trauma patients. OBJECTIVE To determine the test characteristics of a 4-item drug CAGE questionnaire to detect DUDs in a cohort of adult trauma inpatients. METHODS Observational cross-sectional cohort of 1,115 adult patients admitted directly to a level-one trauma center between September, 1994 and November, 1996. All participants underwent both a 4-item drug CAGE questionnaire and the substance use disorder section of a structured psychiatric diagnostic clinical interview (SCID) (DSM-IIIR criteria), administered by staff unaware of their clinical status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), positive (LR+) and negative likelihood ratios (LR-), and the area under the receiver operating curve (AUC) were calculated for each individual question and the overall questionnaire, using SCID-generated DUD diagnoses as the standard. Performance characteristics of the screen were also compared across selected sociodemographic, injury mechanism, and diagnostic sub-groups. RESULTS Subjects with DUDs were common (n = 349, 31.3%), including cannabis (n = 203, 18.2%), cocaine (n = 199, 17.8%), and opioids (n = 156, 14.0%). The screen performed well overall (AUC = 0.90, 95% CI: 0.88-0.91) and across subgroups based on age, sex, race, marriage status, income, education, employment status, mechanism of injury, and current/past DUD status (AUCs 0.75-1.00). Answering any one question in the affirmative had a sensitivity = 83.4% (95% CI: 79.1-87.1), specificity = 92.3% (95% CI: 90.2-94.1), PPV = 83.1%, LR+ = 10.8. CONCLUSIONS The 4-item drug CAGE and its individual questions had good-to-excellent ability to detect DUDs in this adult trauma inpatient population, suggesting its usefulness as a screening tool.

Repeat lactate level predicts mortality better than rate of clearance

Background: Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24‐hour and in‐hospital mortality after injury. Study design: Retrospective chart review of patients admitted to a Level‐1 trauma center directly from the scene of injury from 2010 to 2013 who survived >15 min, had an elevated lactate at admission (≥3 mmol/L), followed by another measurement within 24 h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24 h and in‐hospital mortality. Results: 3910 patients had an elevated admission lactate concentration on admission (mean = 5.6 ± 3.0 mmol/L) followed by a second measurement (2.7 ± 1.8 mmol/L). Repeat absolute measurement best predicted 24‐hour (AUC = 0.85, 95% CI: 0.84–0.86) and in‐hospital death (AUC = 0.77; 95% CI, 0.76–0.78). Relative clearance was the best model of lactate clearance (AUC = 0.77, 95% CI: 0.75–0.78 and AUC = 0.705, 95% CI: 0.69–72, respectively) (p < 0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results. Conclusions: The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.