Early Discharge versus 6-hour Observation in Mild Traumatic Brain Injury with Normal Brain CT Scan; a Comparative Pilot study of Outcomes.

Introduction: Early discharge from the emergency department (ED) or a 6-hour observation in the ED are two methods for management of patients with mild traumatic brain injury (mTBI) with normal brain computed tomography (CT) scan. This study aimed to compare the outcomes of the two management options. Methods: This study is a single-center, open-label, pilot randomized case control study conducted in the ED of Ramathibodi Hospital from June 2022 to September 2023. Eligible participants included all individuals with mTBI who had negative findings on Brain CT scans. They were randomly assigned to either the early ED discharge or 6-hour ED observation group and compared regarding the outcomes (rate of 48-hour ED revisits; occurrence of post-concussion syndrome (PCS) 1 day, 1 month, and 3 months after the initial injury; and 3-month mortality). Results: 122 patients with the mean age of 74.62 ± 14.96 (range: 25-99) years were consecutively enrolled (57.37% female). No significant differences were observed between the early discharge and observation groups regarding the severity of TBI (p=0.853), age (p=0.334), gender (p=0.588), triage level (p=0.456), Glasgow Coma Scale (GCS) score (p=0.806), comorbidities (p=0.768), medication usage (p=0.548), mechanism of injury (p=0.920), indication for brain CT scan (p=0.593), time from TBI onset to ED arrival (p=0.886), and time from ED triage to brain CT scan (p=0.333). Within 48 hours after randomization, the incidence of revisits was similar between the two groups (1.57% vs. 3.23%; p = 1.000). There were no statistically significant differences in the incidence of PCS between the early discharge and observation groups at 1 day (33.90% vs. 35.48%, p = 0.503), at 1 month (12.07% vs. 13.11%, p = 0.542), and at 3 months (1.92% vs. 5.56%, p = 0.323) after randomization. After a three-month follow-up period, four patients in the early discharge group, had expired (none of the deaths were associated with TBI). Conclusion: It seems that, in mTBI patients with normal initial brain CT scan and the absence of other injuries or neurological abnormalities, early discharge from the ED without requiring observation could be considered safe.

Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department.

Purpose: Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department. Patients and Methods: This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation. Results: In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH. Conclusion: Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.

The Clinical Predictive Score for Prehospital Large Vessel Occlusion Stroke: A Retrospective Cohort Study in the Asian Country.

Background: Large vessel occlusive (LVO) stroke causes severe disabilities and occurs in more than 37% of strokes. Reperfusion therapy is the gold standard of treatment. Studies proved that endovascular thrombectomy (EVT) is more beneficial and decreases mortality. This study aimed to evaluate the factor associated with LVO stroke in an Asian population and to develop the scores to predict LVO in a prehospital setting. The score will hugely contribute to the future of stroke care in prehospital settings in the aspect of transferal suspected LVO stroke patients to appropriate EVT-capable stroke centers. Methods: This study was a retrospective cohort study using an exploratory model at the emergency department of Ramathibodi Hospital, Bangkok, Thailand, between January 2018 and December 2020. We included the stroke patients aged >18 who visit ED and an available radiologic report representing LVO. Those whose stroke onset was >24 hours and no radiologic report were excluded. Multivariable logistic regression analysis developed the prediction model and score for LVO stroke. Results: A total of 252 patients met the inclusion criteria; 61 cases (24%) had LVO stroke. Six independent factors were significantly predictive: comorbidity with atrial fibrillation, clinical hemineglect, gaze deviation, facial palsy, aphasia, and cerebellar sign abnormality. The predicted score had an accuracy of 92.5%. The LVO risk score was categorized into three groups: low risk (LVO score <3), moderate risk (LVO score 3-6), and high risk (LVO score >6). The positive likelihood ratio to predicting LVO stroke were 0.12 (95% CI 0.06-0.26), 2.33 (95% CI 1.53-3.53) and 45.40 (95% CI 11.16-184.78), respectively. Conclusion: The Large Vessel Occlusion (LVO) Risk Score provides a screening tool for predicting LVO stroke. A clinical predictive score of ≥3 appears to be associated with LVO stroke.

A Clinical Score for Predicting the Paroxysmal Supraventricular Tachycardia's Recurrence Risk; a Retrospective Cross-sectional Study.

Introduction: Identifying prognostic variables associated with the probability of recurrent paroxysmal supraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. This study aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration in the emergency department (ED). Methods: This retrospective cross-sectional study was conducted on patients who were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiary care hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 until 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the response to standard treatment and the independent predictors of recurrence were studied using multivariable logistic regression analysis. Results: 264 patients were diagnosed with PSVT and successfully converted by adenosine. 24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVT recurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052), heart rate ≥ 100 (p = 0.012), and systolic blood pressure < 100 after electrocardiogram (ECG) converted to sinus rhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT recurrence with an accuracy of 79.5%. A score of 0 (low risk), 1-2 (moderate risk), and > 2 (high risk) had a positive likelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively. Conclusion: It seems that, using the PSVT recurrence score we could screen the high-risk patients for PSVT recurrence (score>2) who need to be observed for at least 6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2) need to be observed for 1 hour and can be discharged from ED.

The Use of qSOFA, SOFA, and Ramathibodi Early Warning Score (REWS) to Predict Severe Complications in Hematologic Malignancy Patients.

BACKGROUND: Sepsis causes high mortality in vulnerable groups such as hematologic malignancy (HM) patients. There are various early warning scores of sepsis, eg, qSOFA, SOFA, and Ramathibodi Early Warning Score (REWS). This study aimed to compare REWS, qSOFA, and SOFA in predicting severe complications in hematologic malignancy patients visiting ED. METHODS: The study was conducted as a retrospective cohort study at the ED of Ramathibodi Hospital, Bangkok, Thailand. Adult HM patients suspected of sepsis and have visited ED between March 2016 and December 2019. RESULTS: Among 124 patients in our cohort, 51 (41%) had serious complication in ED and 20 (16%) died within 28 days after admission. The AUROCs of SOFA and qSOFA indicate significantly higher predicting in serious complication in ED than REWS (SOFA, 0.81 [95% CI, 0.73-0.89], qSOFA, 0.73 [95% CI, 0.65-0.81], REWS, 0.62 [95% CI, 0.52-0.72] p=0.004) while the predicting in 28-day mortality is not statistically significantly different (SOFA, 0.73 [95% CI, 0.60-0.85], qSOFA, 0.69 [95% CI, 0.58-0.80], REWS, 0.60 [95% CI, 0.44-0.75] p=0.25). CONCLUSION: The SOFA score is highest in predicting severe complications among hematologic malignancy patients.

Clinical Prediction Score for Successful Weaning from Noninvasive Positive Pressure Ventilation (NIPPV) in Emergency Department; a Retrospective Cohort Study.

Introduction: Due to the lack of in-hospital beds, some patients with acute cardiogenic pulmonary edema are initiated and weaned off noninvasive positive pressure ventilation (NIPPV) at the emergency department (ED). This study aimed to develop a clinical score to predict successful weaning from NIPPV in these patients. Methods: This retrospective cohort study was conducted on patients with acute cardiogenic pulmonary edema who received NIPPV at the ED of Ramathibodi Hospital, Bangkok, Thailand. Multivariable logistic regression analysis was used to developed a predictive model for weaning from NIPPV. Results: 355 patients with acute cardiogenic pulmonary edema treated with NIPPV were studied (107 (30.14%) failed to be weaned). The significant risk factors of weaning failure based on multivariate analysis were age > 75 years (OR: 3.1, 95% CI: 1.15-8.33, p = 0.025), pneumonia (OR: 2.72, 95% CI: 1.39-5.31, p = 0.003), pulse rate > 80 bpm before NIPPV (OR: 1.74, 95% CI: 1.04-2.91, p = 0.033), and a urinary output < 150 cc/h while using NIPPV (OR: 2.93, 95% CI: 1.74-4.91, p < 0.001). In addition, clinically significant risk factors for weaning from NIPPV were age 60 - 75 years, respiratory rate > 26 breaths/min before weaning and oxygen saturation of < 97% as assessed by pulse oximetry before weaning from NIPPV. Since the lowest coefficient obtained was 0.46, the scores were split into groups of 0.5 points for each factor. Based on the area under the receiver operating characteristic (ROC) curve (71.3% (95% CI: 66.0-75.7%)), the cut point of risk score was divided into the low-risk with positive likelihood ratio of 0.48 (95% CI 0.33-0.69, P <0.001), the moderate-risk with positive likelihood ratio of 0.74 (95%CI 0.52-1.05, P = 0.080), and the high-risk group with positive likelihood ratio of 3.41 (95%CI 2.39-4.88, P <0.001) for predicting weaning failure. Conclusions: In patients with acute cardiogenic pulmonary edema under the NIPPV, weaning is associated with a significant increasing risk of failure in age >75, presence of pneumonia, heart rate > 80 bpm before weaning, and urinary output < 150 cc/h during ventilation. Based on the designed model in this study, patients with score ≤ 3.5, 4-5, and > 5 points were in low, moderate, and severe risk of weaning failure, respectively.

Comparison of chest compression quality between 2-minute switch and rescuer fatigue switch: A randomized controlled trial.

Background: Rescuers performing chest compressions (CCs) should be rotated every 2 min or sooner if rescuers become fatigued. Is it preferable to switch rescuers when they become fatigued in such cases? This study was performed to compare the quality of CCs between two scenarios in hospitalized patients with cardiac arrest: 2-minute rescuer switch and rescuer fatigue switch. Methods: This randomized controlled trial involved 144 health-care providers, randomized to switch CC on the manikin model with 2-minute or rescuer fatigue. We recorded the CC quality for 20 min. Results: There were no significant differences in the percentage of target compressions, mean depth of compressions, or mean compression rate between the two groups. However, the rescuer fatigue switch group showed a significantly lower frequency of interruptions (4 vs. 9 times, P < 0.001) and a longer duration of each compression cycle (237 vs. 117 sec, P < 0.001). The change in the respiratory rate from before to after performing compressions was significantly greater in the 2-minute switch group (12 vs. 8 bpm, P = 0.036). Conclusion: The use of a rescuer fatigue switch CC approach resulted in no decrease in the quality of CC, suggesting that it may be used as an alternate strategy for managing in-hospital cardiac arrest.

Success Rate on Endotracheal Intubation with Prone versus Kneeling Position in Mannequin Model with Limitation of Neck Movement: A Cross Over Study.

Purpose: Endotracheal intubation is a lifesaving procedure for airway management but is more complex when performed in patients lying on the ground and requiring cervical spine immobilization. This study aims to compare the optimal technique between prone and kneeling positions in increasing intubation success rate on these prehospital trauma patients. Patients and Methods: This study was an experimental study on a mannequin. Paramedic students performed intubation on the supine mannequin, which was applied with a rigid cervical collar and manual in-line stabilization. The participants were randomly assigned to intubate in a prone or kneeling position as the first method, then perform another method seven days later. Study outcomes include the percentage of successful intubation, time to perform intubation successfully, and Cormack and Lehane's classification of laryngeal view. Results: Thirty-nine participants were enrolled in this study; 22 were male (56.41%). The mean age, weight, and height were 23.15 ± 4.75 years, 67.38 ± 17.39 kg, and 167.36 ± 8.70 cm., respectively. The percentage of successful intubation in prone (37 [94.90%]) was higher than kneeling position (35 [89.74%]), but there was no statistically significant (p-value = 0.675). Time to intubation successfully, the number of attempts, and Cormack & Lehane's laryngeal view classification were not significantly different between prone and kneeling groups (p-value = 0.808, 0.814, and 0.948, respectively). Conclusion: Intubation with the prone or kneeling position on a mannequin, lying on the ground with cervical spine immobilization, has no statistical difference. Both intubation approaches appear to be effective in successful and rapid intubation, proper glottic visualization and low attempts.

Difficult Laryngoscopy Prediction Score for Intubation in Emergency Departments: A Retrospective Cohort Study.

Objective: Difficult laryngoscopy is associated with difficult intubation, an increasing number of endotracheal intubation attempts, and adverse events. Clinical prediction of difficult airways in an emergency setting was limited in sensitivity and specificity. This study developed a new model for predicting difficult laryngoscopy in the emergency department. Methods: This retrospective cohort study was conducted using an exploratory model at the Emergency Medicine of Ramathibodi Hospital. The study was conducted from June 2018 to July 2020. The eligibility criteria were an age of ≥15 years who undergo intubation in the emergency department. Difficult laryngoscopy was defined as a Cormack-Lehane grade 3 and above. The predictive model and score were developed by multivariable logistic regression analysis. Results: A total of 617 patients met the eligibility criteria; 83 (13.45%) had difficult laryngoscopy. Five independent factors were predictive of difficult laryngoscopy. Significant factors were M: limited mouth opening, O: presence of obstructed airway, N: poor neck mobility, T: large tongue, and H: short hypo-mental distance. The difficult laryngoscopy score had an accuracy of 89%. A score of >4 increased the likelihood ratio of difficult laryngoscopy by 7.62 times. Conclusion: The MONTH Difficult Laryngoscopy Score of >4 was associated with difficult laryngoscopy.

Clinical Prediction Score for Early Diagnosis of Acute Pancreatitis in Emergency Departments.

Background: In Thailand, most primary care hospitals cannot measure serum lipase and amylase; no 24 hours computed tomography and magnetic resonance imaging available, and no on-call gastroenterologists. Thus, acute pancreatitis cannot be diagnosed based on the established diagnostic criteria that require this information. The resultant delayed management increases morbidity and mortality. This study was performed to create a clinical prediction score for early diagnosis of acute pancreatitis in emergency departments without requiring a computed tomography scan or laboratory measurement to assist in the initial diagnosis, treatment, or referral. Methods: Patients with suspected acute pancreatitis who had available data regarding lipase and amylase measurements and visited the emergency department from June 2019 to August 2020 were retrospectively analyzed. The baseline predictive factors were compared between patients with and without acute pancreatitis according to the 2012 revised Atlanta classification. Multivariable logistic regression was used to explore potential predictive factors and develop a clinical prediction score for the diagnosis of acute pancreatitis. Results: A total of 506 eligible patients, 84 (16%) had acute pancreatitis. The PRE-PAN score [area under the receiver operating characteristics curve, 0.88; 95% confidence interval (CI), 0.84-0.93] included six factors: alcohol drinking, epigastric pain, pain radiating to the back, persistent pain, nausea or vomiting, and the pain score. A score of >7.5 points suggested a high probability of acute pancreatitis [positive likelihood ratio, 6.80 (95% CI, 4.75-9.34; p < 0.001); sensitivity, 66.7% (95% CI, 54.6-77.3); specificity, 90.2% (95% CI, 86.6-93.1); positive predictive value, 58.5% (95% CI, 47.1-69.3);, 92.9% (95% CI, 89.6-95.4)]. Conclusion: A PRE-PAN risk score is a screening tool for predicting acute pancreatitis without using the lipase concentration or radiological findings. A high predictive score, especially >7.5, suggests a high probability of acute pancreatitis.

Mortality in patients receiving prolonged invasive mechanical ventilation time in the emergency department: A retrospective cohort study.

Background: Patients waiting for intensive care unit (ICU) admission cause emergency department (ED) crowding and have an increased risk of mortality and length of stay (LOS) in hospital, which increase the hospitalization cost. This study aimed to investigate the correlation between mortality and invasive mechanical ventilation (IMV) time in patients in the ED. Methods: A retrospective cohort study was conducted in patients who received IMV in the ED of Ramathibodi Hospital. The correlation between mortality at 28 days after intubation and IMV time in the ED was analyzed. The cutoff time was analyzed to determine prolonged and nonprolonged IMV times. ICU ventilation time, length of ICU stay, and LOS in the hospital were also analyzed to determine their correlations between IMV time in the ED. Results: In this study, 302 patients were enrolled, 71 died, and 231 survived 28 days after receiving IMV in the ED. We found that the duration of >12 h of IMV in the ED increased the 28-day mortality rate by 1.98 times (P = 0.036). No correlations were found between IMV time in the ED and ventilation time in the ICU, length of ICU stay, and LOS in the hospital. Conclusion: More than 12 h of IMV time in the ED correlated with mortality at 28 days after initiation of IMV. No associations were found between prolonged IMV time in the ED with ventilation time in the ICU, length of ICU stay, and LOS in the hospital.

Straddle versus Conventional Chest Compressions in a Confined Space; a Comparative Study.

INTRODUCTION: When cardiac arrest occurs in a confined space, such as in an aircraft or ambulance, kneeling by the patient's side may be difficult. Straddle chest compression is an alternative technique that can be used in a confined space. This study was performed to compare the quality of chest compressions in straddle versus conventional CPR on a manikin model. METHODS: The participants were randomized into two groups using the sequential numbered, opaque, sealed envelope method chosen through block-of-four randomization: straddle and conventional chest compression technique. Each participant performed a maximum of 4 minutes of hands-only chest compressions, and quality parameters (compression rate and depth) were recorded from the defibrillator's monitor. RESULTS: 124 participants with mean age of 26.67 ± 6.90 years (27.58% male) were studied. There was no difference in the mean compression rate between the conventional and straddle chest compression techniques (126.18 ± 17.11 and 127.01 ± 21.01 compressions/min, respectively; p = 0.811) or their mean compression depth (43.8 ± 9.60 and 43.4 ± 9.10 mm, respectively; p = 0.830). The participants' comfort and fatigue were assessed through changes in their vital signs. In both methods, statistically significant differences were observed in vital signs before and after performing chest compression, but the differences were not clinically significant. In addition, there was no difference between the 2 groups in this regard. CONCLUSION: The quality of CPR using the straddle chest compression was as good as conventional chest compression technique. No significant differences were found in the quality of chest compressions or the participants' comfort and fatigue levels.

Effectiveness of a Dispatcher-Assisted Cardiopulmonary Resuscitation Program Developed by the Thailand National Institute of Emergency Medicine (NIEMS).

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a life-threatening condition with an overall survival rate that generally does not exceed 10%. Several factors play essential roles in increasing survival among patients experiencing cardiac arrest outside the hospital. Previous studies have reported that implementing a dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) program increases bystander CPR, quality of chest compressions, and patient survival. This study aimed to assess the effectiveness of a DA-CPR program developed by the Thailand National Institute for Emergency Medicine (NIEMS). METHODS: This was an experimental study using a manikin model. The participants comprised both health care providers and non-health care providers aged 18 to 60 years. They were randomly assigned to either the DA-CPR group or the uninstructed CPR (U-CPR) group and performed chest compressions on a manikin model for two minutes. The sequentially numbered, opaque, sealed envelope method was used for randomization in blocks of four with a ratio of 1:1. RESULTS: There were 100 participants in this study (49 in the DA-CPR group and 51 in the U-CPR group). Time to initiate chest compressions was statistically significantly longer in the DA-CPR group than in the U-CPR group (85.82 [SD = 32.54] seconds versus 23.94 [SD = 16.70] seconds; P <.001). However, the CPR instruction did not translate into better performance or quality of chest compressions for the overall sample or for health care or non-health care providers. CONCLUSION: Those in the CPR-trained group applied chest compressions (initiated CPR) more quickly than those who initiated CPR based upon dispatch-based CPR instructions.

Prediction Score for Cervical Spine Fracture in Patients with Traumatic Neck Injury.

BACKGROUND: Cervical spine fracture is approximately 2%-5%. Diagnostic imaging in developing countries has several limitations. A computed tomography scan is not available 24 hours and not cost-effective. This study aims to develop a clinical tool to identify patients who must undergo a computed tomography scan to evaluate cervical spine fracture in a noncomputed tomography scan available hospital. METHODS: The study was a diagnostic prediction rule. A retrospective cross-sectional study was conducted between August 1, 2016, and December 31, 2018, at the emergency department. This study included all patients aged over 16 years who had suspected cervical spine injury and underwent a computed tomography scan at the emergency department. The predictive model and prediction scores were developed via multivariable logistic regression analysis. RESULTS: 375 patients met the criteria. 29 (7.73%) presented with cervical spine fracture on computed tomography scan and 346 did not. Five independent factors (i.e., high-risk mechanism of injury, paraparesis, paresthesia, limited range of motion of the neck, and associated chest or facial injury) were considered good predictors of C-spine fracture. The clinical prediction score for C-spine fracture was developed by dividing the patients into three probability groups (low, 0; moderate, 1-5; and high, 6-11), and the accuracy was 82.52%. In patients with a score of 1-5, the positive likelihood ratio for C-spine fracture was 1.46. Meanwhile, those with a score of 6-11 had an LR+ of 7.16. CONCLUSION: In a noncomputed tomography scan available hospital, traumatic spine injuries patients with a clinical prediction score ≥1 were associated with cervical spine fracture and should undergo computed tomography scan to evaluate C-spine fracture.

Decision-Making by Emergency Medicine Personnel in Prehospital Treatment of Patients Receiving Palliative Care: A Questionnaire, Comparative Cohort Study.

OBJECTIVE: Palliative care is an approach to improve quality of life in patients with life-limiting diseases. The sudden nature of such conditions involves emergency providers as the first responders, who have roles in delivering appropriate care to meet patients' needs. In this study, we evaluated whether previous experience in palliative care among paramedic students could affect their decision-making skills in prehospital work. METHODS: This questionnaire-based prospective cross-sectional study was conducted from October 2019 to November 2020. We compared two groups of paramedic students in a tertiary hospital in Bangkok, Thailand. The class of 2019 did not attend palliative care courses and the class of 2020 completed a 2-week course regarding in-hospital palliative care services. Questionnaires including rating scales and checklists and involving cases with and without malignancy were completed via a web-based data collection form. The reliability of the questionnaire was tested. Decision-making skills were categorized into seven domains comprising life-sustaining treatment, withholding or withdrawing life-sustaining treatment, advance care planning, self-autonomy, decision-making capacity and surrogate decision-makers, prehospital dyspnea management, and communication skills. RESULTS: Among 57 paramedics, 52 (91%) completed the questionnaire. There was no significant difference in decision-making between the two groups in all seven domains (p>0.050). Overall, participants more often recognized patients who were eligible for palliative care and made more decisions to withhold or withdraw life-sustaining treatment when patients had advanced malignancy than in cases of non-malignancy (100% and 84.6% respectively, p=0.006). CONCLUSION: Our findings showed that the decision-making process for patients regarding prehospital palliative care was not significantly different between two groups of emergency personnel with and without in-hospital palliative care experience.

Mortality Rate of Trauma Patients with ESI Triage Level 1-2 Who Underwent Computerized Tomography-PANSCAN versus Conventional Computerized Tomography Scan.

OBJECTIVE: The treatment of severe trauma patients requires a fast and accurate method to diagnose life-threatening conditions. Computerized tomography (CT)-PANSCAN has been widely used for the last 20 years to diagnose many patients in critical condition. However, no research has been performed into the efficacy of CT-PANSCAN. This research aims to compare the mortality rate of trauma patients who underwent CT-PANSCAN versus conventional CT scan. METHODS: This retrospective cohort study enrolled patients who were at triage ESI level 1-2 in the emergency department of Ramathibodi Hospital from January 2013 to December 2018 and analyzed the mortality rate between those who underwent CT-PANSCAN and conventional CT scan. RESULTS: The study enrolled 123 trauma patients; 61 patients underwent CT-PANSCAN, whereas 62 patients underwent conventional CT scan. There were 1 and 7 patients who expired in the CT-PANSCAN and conventional CT scan groups, respectively. After multivariate regression analysis, the result revealed that patients who underwent CT-PANSCAN had a lower mortality rate (adjusted odds ratio = 0.023; p-value = 0.018; 95% CI 0.001-0.518). CONCLUSION: Undergoing a CT-PANSCAN can reduce the mortality rate in trauma patients, especially in ESI level 1, 2 traumatic patients, and CT-PANSCAN available facilities.

Clinical Prediction Score for Ruptured Appendicitis in ED.

BACKGROUND: Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population. METHODS: This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis. RESULT: During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times. CONCLUSION: Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Validity of mild TBI risk score to predict intracranial hemorrhage in cases of mild traumatic brain injury in Thailand.

BACKGROUND: Patients with mild traumatic brain injury (TBI) will receive a brain CT scan based on risk of injury. A previous study established a scoring system for patients with mild TBI that assigned <3 points for the low-risk group, 3-6 points for the moderate-risk group, and ≥6 points for the high-risk group. The purpose of this study was to evaluate the external validity of mild TBI risk scores for predicting intracranial hemorrhage in patients with mild TBI who had been transferred to receive a brain CT scan at the 10 nationwide CT scan-capable facilities in Thailand. METHODS: The study was a retrospective cross-sectional review of patients with mild TBI who received a brain CT scan in 10 nationwide hospitals of Thailand. Risk factors were observed and points calculated for predicting mild TBI scores based on patient records. Injured patients were divided into two groups: CT scans indicating normal and abnormal brain images. After this, the accuracy of mild TBI score for predicting the presence of intracranial hemorrhage was investigated. RESULTS: The study included a total of 999 patients, comprising 461 (46.15%) patients with abnormal brain CT scans indicating intracranial hemorrhage and 538 (53.85%) indicating no intracranial hemorrhage. In the low-risk group (mild TBI risk score <3), moderate-risk group (mild TBI risk score 3-6), and high-risk group (mild TBI risk score >6), the likelihood ratio positive of brain CT scans were 0.41, 3.53, and 77.3, respectively. DISCUSSION: Mild TBI risk score may assist healthcare providers to select patients with mild TBI for brain CT scan referral, particularly in hospitals without CT scan facilities. In such cases, based on the proposed scoring system, immediate transfer of moderate-risk and high-risk patients with mild TBI to a CT scan-capable facility is necessary.