Proposed Mechanism-Based Risk Stratification and Algorithm to Prevent Sudden Death in Epilepsy.

Sudden Unexpected Death in Epilepsy (SUDEP) is the leading cause of death in young adults with uncontrolled seizures. First aid guidance to prevent SUDEP, though, has not been previously published because the rarity of monitored cases has made the underlying mechanism difficult to define. This starkly contrasts with the first aid guidelines for sudden cardiac arrest that have been developed based on retrospective studies and expert consensus and the discussion of resuscitation challenges in various American Heart Association certificate courses. However, an increasing amount of evidence from documented SUDEP cases and near misses and from animal models points to a consistent sequence of events that starts with sudden airway occlusion and suggests a mechanistic basis for enhancing seizure first aid. In monitored cases, this sudden airway occlusion associated with seizure activity can be accurately inferred from inductance plethysmography or (depending on recording bandwidth) from electromyographic (EMG) bursts that are associated with inspiratory attempts appearing on the electroencephalogram (EEG) or the electrocardiogram (ECG). In an emergency setting or outside a hospital, seizure first aid can be improved by (1) keeping a lookout for sudden changes in airway status during a seizure, (2) distinguishing thoracic and abdominal movements during attempts to inspire from effective breathing, (3) applying a simple maneuver, the laryngospasm notch maneuver, that may help with airway management when aggressive airway management is unavailable, (4) providing oxygen early as a preventative step to reduce the risk of death, and (5) performing cardiopulmonary resuscitation before the limited post-ictal window of opportunity closes. We propose that these additions to first aid protocols can limit progression of any potential SUDEP case and prevent death. Risk stratification can be improved by recognition of airway occlusion, attendant hypoxia, and need for resuscitation.

Computerized cognitive performance assessments in the Brooklyn Cognitive Impairments in Health Disparities Pilot Study.

INTRODUCTION: Detecting cognitive impairment in diverse, health disparities communities is an urgent health care priority. METHODS: The Brooklyn Cognitive Impairments in Health Disparities Pilot Study investigated quantitative aspects and liking of a computerized cognitive performance assessment, Cognigram, among individuals ≥ 40 years in traditional and nontraditional primary care settings. RESULTS: Cognigram was piloted in the Emergency Department, Family Medicine, and Geriatric Psychiatry clinics: 58 adults (23 men, 35 women), 67.9 ± 9.8 years (range 43-91), completed the Cognigram and 5-item liking survey. The observed liking range was 2 to maximum score 5 (67% scored 4-5; no sex or age differences). DISCUSSION: The Cognigram was well liked in waiting rooms of primary care settings. Assistance from a trained adult and clinic endorsement were keys to success. How the Cognigram performs in a geographically compact, population-dense global setting, such as Brooklyn with high vascular disease risk and a plethora of health disparities, is being tested.

A Resuscitation Option for Upper Airway Occlusion Based on Bolus Transtracheal Lung Inflation.

BACKGROUND: Acute laryngospasm sufficient to cause obstructive apnea is a medical emergency that can be difficult to manage within the very short time available for establishing an airway. We have presented substantial evidence that laryngospasm-based obstructive apnea is the cause of sudden death in epilepsy, and airway management is particularly challenging during seizure activity. OBJECTIVE: We sought to determine if the transtracheal delivery of a bolus of oxygen or room air below the level of an obstruction to inflate the lungs could be an effective method to prolong the time available for responders seeking to establish a stable airway, and, if so, what could be learned about optimization of delivery parameters from a rat model. METHODS: Rats were fitted with a t-shaped tracheal tube for controlling access to air and for measuring airway pressures. After respiratory arrest from simulated laryngospasm, bolus transtracheal lung inflation with a volume of gas equivalent to half the vital capacity was delivered to the closed respiratory system as the only resuscitation step. RESULTS: Bolus lung inflation was sufficient for resuscitation, improving cardiac function and re-establishing adequate oxygen status to support life. Inflation steps could be repeated and survival times were approximately 3 times that of non-inflated lungs. CONCLUSION: The properties and consequences of bolus lung inflation are described as a foundation for procedures or devices that can be useful in cases of severe laryngospasm and other cases of upper airway obstruction. LEVEL OF EVIDENCE: 3.

The impact of wound age on the infection rate of simple lacerations repaired in the emergency department.

BACKGROUND: The influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ED) has not been well studied. It has traditionally been taught that there is a "golden period" beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. The proposed cutoff for this golden period has been highly variable (3-24h in surgical textbooks). Our objective is to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection? METHODS: We searched MEDLINE, EMBASE, and other databases as well as bibliographies of relevant articles. We included studies that enrolled ED patients with lacerations repaired by primary closure. Exclusion: (1) delayed primary repair or secondary closure, (2) wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and (3) grossly contaminated or infected at presentation. We compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). We used "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) criteria to assess the quality of the included trials. RESULTS: 418 studies were identified. Four trials enrolling 3724 patients in aggregate met our inclusion/exclusion criteria. The overall quality of evidence was low. The infection rate in the wounds that presented with delay ranged from 1.4% to 32%. One study with the smallest sample size (only 19 delayed wounds), which only enrolled lacerations to hand and forearm, showed higher rate of infection in patients with delayed (older than 12h) wounds (relative risk of infection: 4.8, 95% confidence interval, 1.9-12.0). The infection rate in delayed wound groups in the remaining three studies was not significantly different. CONCLUSION: The existing evidence does not support the existence of a golden period nor does it support the role of wound age on infection rate in simple lacerations.

Using a joint triage model for multi-hospital response to a mass casualty incident in New York city.

This paper defines a specific plan which allows two separate institutions, with different capabilities, to function as a single receiving entity in the event of a mass casualty incident. The street between the two institutions will be closed to traffic and a two-phase process initiated. Arriving ambulances will first be quickly screened to expedite the most critical patients followed by formal triage and directing patients to one of the two facilities. Preparation for this plan requires prior coordination between local authorities and the administrations of both institutions. This plan can serve as a general model for disaster preparedness when two or more institutions with different capabilities are located in close proximity.

The rate of sexually transmitted infections in ED patients with vaginal bleeding.

BACKGROUND: Early diagnosis of sexually transmitted infections (STI) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) is crucial in reducing complications. Vaginal bleeding (VB) has been suggested as a possible presentation of STI. OBJECTIVE: To identify the rate of STI in sexually active women presenting to the emergency department (ED) with VB. METHODS: Prospective observational study of females 18-55 years-old presenting to two affiliated urban EDs with VB (convenience sample). Patients with recent STI or antibiotic use (< 3 months) were excluded. To estimate the background rate of STI, we enrolled women with no genitourinary complaints as controls. Specimens for CT and NG were obtained during speculum exam from cases and by self administered vaginal swab in controls. All specimens were analyzed by polymerase chain reaction. Continuous data was presented as mean +/- standard deviation and categorical data as percentages with 95% confidence intervals CI). Fisher's exact test was used to compare the rate of STI between the groups. RESULTS: From 09.06 to 08.07 a total 273 subjects were enrolled (174 VB and 99 controls, mean age: 33 +/- 10). Groups were similar with regards to baseline characteristics. The majority of STI cases were due to CT: 5.8% in VB group (95% CI, 3.2%-10.4%) vs. 7.1% in controls (95% CI, 3.5%-14.0%). The STI rate was 6.3% (95% CI, 3.5%-11.1%) in VB patients and 8% (95% CI, 3.9%-15.3%) in controls. CONCLUSIONS: Our ED patients with and without vaginal bleeding had comparable rate of STI.

Self-administered vaginal swabs are a feasible alternative to physician-assisted cervical swabs for sexually transmitted infection screening in the emergency department.

BACKGROUND: Screening for sexually transmitted infections (STIs) in the emergency department (ED) is limited by the need for pelvic examination. It has been suggested that using self-administered vaginal swabs (SAVS) for this purpose may save time and resources and may be more comfortable for patients. OBJECTIVES: The objective was to test the feasibility of using SAVS for STI screening in the ED. METHODS: This was a prospective study of female ED patients 18 to 55 years old who consented to physician-assisted cervical swab (PACS) and SAVS in two urban teaching hospitals. The ED personnel offered the test to all patients, whether or not a pelvic examination was indicated, based on their chief complaint. All specimens were analyzed by polymerase chain reaction (PCR) assay. Data are presented as mean +/- standard deviation (SD). Categorical data are presented as percentages with 95% confidence intervals (CIs). Patients with a positive test result for Chlamydia trachomatis and/or Neisseria gonorrhoeae were considered positive for STI. PACS were used as the criterion standard. RESULTS: One-hundred sixty-two subjects were enrolled from July 2006 to July 2007 (mean [+/-SD] age = 32 [+/-10] years). Eighty-one percent of patients had a genitourinary symptom (most common: vaginal bleeding/spotting). SAVS had a sensitivity of 91% (95% CI = 60% to 99%), specificity of 99% (95% CI = 95% to 99%), positive likelihood ratio of 91, and negative likelihood ratio of 0.09 in diagnosing STIs. None of the patients reported difficulty or discomfort using this technique. CONCLUSIONS: Self-administered vaginal swabs can be utilized as a feasible alternative to PACS for STI screening in the ED.

Is routine electrolyte testing necessary for diabetic patients who present to the emergency department with moderate hyperglycemia?

OBJECTIVES: No consensus standard is established for the workup of diabetic patients with moderate hyperglycemia [fingerstick glucose of 11.00-33.00 mmol/l (200-600 mg/dl)]. We measured the incidence of serious electrolyte abnormalities in patients with moderate hyperglycemia and attempted to identify a subset of these patients who can safely forego routine electrolyte testing. METHODS: Prospective cohort study in two affiliated emergency departments. INCLUSION CRITERIA: Moderate hyperglycemia. EXCLUSION CRITERIA: new onset diabetes or renal failure. The composite outcome was defined as an abnormal potassium K >5.00 or <3.50 mmol/l or diabetic ketoacidosis. Univariate analyses were performed using t-test and Fisher's exact test (alpha=0.05, two-tails). Logistic regression models were generated to identify variables that could predict the composite outcome. RESULTS: Three hundred and ninety-nine adults were enrolled (294 type II, 38% men). Mean age was 59+/-15 (20-97 years) years. The incidence of the composite outcome was 22% (95% confidence interval, 17.8-26.0%, n=86). The univariate analysis identified potassium-altering medications and insulin use as risk factors for the composite outcome. Logistic regression analysis identified potassium-altering medications as an increased risk (relative risk: 1.64, 95% confidence interval, 1.14-2.37) and use of oral hypoglycemics as a decreased risk (relative risk: 0.62, 95% confidence interval, 0.43-0.90) of the composite outcome. Cross-validation of the model demonstrated poor sensitivity (76%) and even worse accuracy (51%). CONCLUSION: We failed to identify any subgroup of patients with moderate hyperglycemia who can be safely excluded from routine electrolyte testing. We recommend routine electrolyte testing for all moderate hyperglycemia patients in the emergency department.

Identifying traumatic brain injury in patients with isolated head trauma: are arterial lactate and base deficit as helpful as in polytrauma?

BACKGROUND: Increase in lactate (LAC) within the central nervous system after head trauma is an established marker of traumatic brain injury (TBI). OBJECTIVE: To investigate the utility of arterial base deficit (BD) and LAC in identifying TBI in patients with isolated head injury (IHI). MATERIALS AND METHODS: TBI was defined as Glasgow Coma Scale < or =8, head Abbreviated Injury Severity Score >2 or brain haematoma on CT scan. Patients were divided into two groups: IHI with and without TBI. Data were reported as means (SDs). 131 patients with IHI were studied (mean (SD) age 39 (19) years, 78% male). RESULTS: 17% of the patients sustained TBI. The mean differences for arterial BD (0.65 mmol/l, 95% CI -0.8 to 2.1) and LAC (0.34 mmol/l, 95% CI -0.7 to 1.4) in patients with and without TBI were not significant. Analysis of receiver operating characteristic curves confirmed that arterial BD and LAC were unable to detect TBI in patients with IHI. CONCLUSION: Arterial BD and LAC are poor predictors of TBI in isolated head trauma.

Effect of normal saline infusion on the diagnostic utility of base deficit in identifying major injury in trauma patients.

BACKGROUND: Base deficit (BD) is a reliable marker of metabolic acidosis and is useful in gauging hemorrhage after trauma. Resuscitation with chloride-rich solutions such as normal saline (NS) can cause a dilutional acidosis, possibly confounding the interpretation of BD. OBJECTIVES: To test the diagnostic utility of BD in distinguishing minor from major injury after administration of NS. METHODS: This was a prospective observational study at a Level 1 trauma center. The authors enrolled patients with significant mechanism of injury and measured BD at triage (BD-0) and at four hours after triage (BD-4). Major injury was defined by any of the following: injury severity score of > or =15, drop in hematocrit of > or = 10 points, or the patient requiring a blood transfusion. Patients were divided into a low-volume (NS < 2L) and a high-volume (NS 2L) group. Data were reported as mean (+/-SD). Student's t- and Wilcoxon tests were used to compare data. Receiver operating characteristic (ROC) curves tested the utility of BD-4 in differentiating minor from major injury in the study groups. RESULTS: Four hundred eighty-nine trauma patients (mean age, 36 [+/-18] yr) were enrolled; 82% were male, and 34% had penetrating injury. Major-(20%) compared with minor-(80%) injury patients were significantly (p = 0.0001) more acidotic (BD-0 mean difference: -3.3 mmol/L; 95% confidence interval [CI] = -2.5 to -4.2). The high-volume group (n = 174) received 3,342 (+/-1,821) mL, and the low-volume group (n = 315) received 621 (+/-509) mL of NS. Areas under the ROC curves for the high-volume (0.63; 95% CI = 0.52 to 0.74) and low-volume (0.73; 95% CI = 0.60 to 0.86) groups were not significantly different from each other. CONCLUSIONS: Base deficit was able to distinguish minor from major injury after four hours of resuscitation, irrespective of the volume of NS infused.

Ethanol and illicit drugs do not affect the diagnostic utility of base deficit and lactate in differentiating minor from major injury in trauma patients.

OBJECTIVES: Base deficit (BD) and lactate are valuable screening tools for injured patients. They reflect the degree of oxygen debt and have been shown to predict outcome. Intake of ethanol and illicit drugs may further derange acid-base status. The authors evaluated the effect of blood alcohol level (BAL) and illicit drugs on admission BD and lactate levels in trauma patients. METHODS: Prospective, observational study of trauma patients in a Level 1 trauma center. Patients with penetrating or blunt trauma were included in the study. Patients were further stratified into major or minor categories. Major was defined by an Injury Severity Score >15, blood transfusions, or a decrease in hematocrit of more than ten points. Injury categories were further divided into several subgroups based on presence or absence of ethanol (BAL > or =0.08 g/dL) or positive urine toxicology screen (Utox). RESULTS: A total of 520 patients (84% male) with a mean (+/-SD) age of 33 (+/-15) years were studied. Compared with the minor injury categories, BD and lactate levels were significantly higher in the major injury categories in all different intoxication subgroups. Testing the diagnostic performance of BD and lactate in detecting major injury, the authors observed significant (p < 0.05) differences between the areas under the receiver operating characteristic curves for these two diagnostic tests compared with baseline in both intoxicated (BAL > or =0.08 g/dL and/or positive Utox) and nonintoxicated (BAL <0.08 g/dL and negative Utox) patients. CONCLUSIONS: The presence of ethanol and/or illicit drugs did not affect the ability of BD or lactate to identify patients with major injuries.