Re-Evaluating Cross-Contamination: Additional Trials on Co-Ventilation.

BACKGROUND: Medical equipment can become scarce in disaster scenarios. Prior work has reported that four sheep could be ventilated together on a single ventilator. Others found that this maneuver is possible when needed, but no one has yet investigated whether cross-contamination occurs in co-ventilated individuals. OBJECTIVE: Our goal was to investigate whether an infection could spread between co-ventilated individuals. METHODS: Four 2-L anesthesia bags were connected to a sterilized ventilator circuit that used heat and moisture exchange filters and bacterial and viral filters, as would be expected in this dire scenario. Serratia marcescens was inoculated into "lung" no. 1. After running for 24 h, each lung and three additional points in the circuit were cultured to see whether S. marcescens had spread. These cultures were examined at 24 and 48 h to assess for cross-contamination. This entire procedure was performed three times. RESULTS: S. marcescens was not found in lung no. 2, 3, or 4 or the three additional sites on the expiratory limb at 24 and 48 h in all three trials. CONCLUSIONS: Cross-contamination does not occur within 24 h using the described ventilator circuit configuration.

Evaluating cross contamination on a shared ventilator.

BACKGROUND: Disasters have the potential to cause critical shortages of life-saving equipment. It has been postulated that during patient surge, multiple individuals could be maintained on a single ventilator. This was supported by a previous trial that showed one ventilator could support four sheep. The goal of our study is to investigate if cross contamination of pathological agents occurs between individuals on a shared ventilator with strategically placed antimicrobial filters. METHODS: A multipatient ventilator circuit was assembled using four sterile, parallel standard tubing circuits attached to four 2 L anaesthesia bags, each representing a simulated patient. Each 'patient' was attached to a Heat and Moisture Exchange filter. An additional bacterial/viral filter was attached to each expiratory limb. 'Patient-Lung' number 1 was inoculated with an isolate of Serratia marcescens, and the circuit was run for 24 hours. Each 'lung' and three points in the expiratory limb tubing were washed with broth and cultured. All cultures were incubated for 48 hours with subcultures performed at 24 hours. RESULTS: Washed cultures of patient 2, 3 and 4 failed to demonstrate growth of S. marcescens. Cultures of the distal expiratory tubing, expiratory limb connector and expiratory limb prefilter tubing yielded no growth of S. marcescens at 24 or 48 hours. CONCLUSION: Based on this circuit configuration, it is plausible to maintain four individuals on a single ventilator for 24 hours without fear of cross contamination.

Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure.

OBJECTIVES: Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B-lines) in patients with hypertensive AHF early in the course of treatment. METHODS: We conducted a feasibility study in a cohort of adults with acute onset of dyspnea, severe hypertension in the field or at triage (systolic blood pressure ≥ 180 mm Hg), and a presumptive diagnosis of AHF. Patients underwent repeated dyspnea and lung sonographic assessments using a 10-cm visual analog scale (VAS) and an 8-zone scanning protocol. Lung sonographic assessments were performed at the time of triage, initial VAS improvement, and disposition from the emergency department. Sonographic pulmonary edema was independently scored offline in a randomized and blinded fashion by using a scoring method that accounted for both the sum of discrete B-lines and degree of B-line fusion. RESULTS: Sonographic pulmonary edema scores decreased significantly from initial to final sonographic assessments (P < .001). The median percentage decrease among the 20 included patient encounters was 81% (interquartile range, 55%-91%). Although sonographic pulmonary edema scores correlated with VAS scores (ρ = 0.64; P < .001), the magnitude of the change in these scores did not correlate with each other (ρ = -0.04; P = .89). CONCLUSIONS: Changes in sonographic pulmonary edema can be semiquantitatively measured by serial 8-zone lung sonography using a scoring method that accounts for B-line fusion. Sonographic pulmonary edema improves in patients with hypertensive AHF during the initial hours of treatment.

Surgical and trauma care in low- and middle-income countries: a review of capacity assessments.

BACKGROUND: Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS: Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS: Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS: Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.

Trauma system development in low- and middle-income countries: a review.

BACKGROUND: Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings. MATERIALS AND METHODS: EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner. RESULTS: A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model. CONCLUSIONS: There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.

Layperson trauma training in low- and middle-income countries: a review.

BACKGROUND: Prehospital trauma systems are rudimentary in many low- and middle-income countries (LMICs) and require laypersons to stabilize and transport injured patients. The World Health Organization recommends educating layperson first responders as an essential step in the development of Emergency Medical Services systems in LMICs. This systematic review examines trauma educational initiatives for layperson first responders in resource-poor settings. MATERIALS AND METHODS: Layperson first-responder training and education program publications were identified using PubMed MEDLINE and Scopus databases. Articles addressing physicians, professional Emergency Medical Services training, or epidemiologic descriptions were excluded. Publications were assessed by independent reviewers, and those included underwent thematic analysis. RESULTS: Thirteen publications met inclusion criteria. Four themes emerged regarding the development of layperson first-responder training programs: (1) An initial needs assessment of a region's existing trauma system of care and laypersons' baseline emergency care knowledge focuses subsequent educational interventions; (2) effective programs adapt to and leverage existing resources; (3) training methods should anticipate participants with low levels of education and literacy; and (4) postimplementation evaluation allows for curriculum improvement. Technology, such as online and remote learning platforms, can be used to operationalize each theme. CONCLUSIONS: Successful training programs for layperson first responders in LMICs identify and maximize existing resources are adaptable to learners with little formal education and are responsive to postimplementation evaluation. Educational platforms that leverage technology to deliver content may facilitate first-responder trauma education in underresourced areas. Themes identified can inform the development of trauma systems of care to decrease mortality and physiological severity scores in trauma patients in LMICs.

A Novel Approach to Noncompressible Torso Hemorrhage Using a Silicone-Based Polymer Universal Combat Matrix.

INTRODUCTION: Battlefield trauma necessitates prompt hemostatic intervention to mitigate fatalities resulting from critical blood loss. Insights from Operation Enduring Freedom and Operation Iraqi Freedom emphasize the limitations of conventional methods, such as tourniquets, especially in noncompressible torso hemorrhage. Despite advancements in hemostatic agents, the evolving dynamics of multidomain operations necessitate novel, lightweight strategies for hemorrhage control. This study investigates the Silicone-Based Polymer (SBP) Universal Combat Matrix (UCM) by SiOxMed, a multimodal matrix exhibiting efficacy in lethal hemorrhage models. The study evaluates UCM's multiday hemostatic capabilities in a noncompressible torso hemorrhage model, offering pivotal insights for potential deployment in battlefield trauma. MATERIALS AND METHODS: This research was performed under Institutional Animal Care and Use Committee approval and was designed to replicate austere conditions in an off-site enclosed facility. Yorkshire Hampshire swine underwent baseline assessments and anesthesia induction (n = 3). A Grade IV liver injury was made by incising X-shaped lesions, each measuring 4 cm × 2.5 cm, into the diaphragmatic surface of the left and right middle lobes using a scalpel blade, resulting in a lesion region of approximately 3 cm × 6 cm × 3 cm, followed by 30 seconds of uncontrolled bleeding. The injuries were then treated with SBP. Intensive care unit monitoring for 1 hour ensured sustained hemostasis, followed by 48 hours of postanesthesia monitoring and then a return to the operating table to visualize sustained hemostasis. Posteuthanasia, liver tissue underwent histological assessments to evaluate the hemorrhagic interface and liver tissue reactivity. RESULTS: The average time to hemostatic control was 247.3 ± 71.3 seconds. Stable heart rate (81.3 ± 10.0) and respiratory rate (31.7 ± 16.5) were maintained during intensive care unit monitoring. All swine survived the 1-hour anesthesia monitoring period and the subsequent 48-hour monitoring (average survival time, 48.0 hours ± 0.0, n = 3). Visualization of the abdominal cavity at 48 hours revealed no hemorrhage. Histological assessment demonstrated aligned red blood cells and stratified layers of fibrin at the hemorrhagic interface. Masson's Trichrome analysis demonstrated a reactive and regenerative scenario 48 hours postinjury, with a collagen membrane demarcating uninjured and exposed liver regions, along with a comprehensive stromal response. CONCLUSIONS: In conclusion, our investigation into the SBP UCM hemostatic efficacy in a grade IV liver laceration model demonstrates its rapid and reliable action in controlling bleeding, showcasing practicality with an average mass of 4.0 ± 1.0 g. Silicone-Based Polymer sustained hemostasis without adverse physiological effects, as evidenced by stable parameters and the survival of all swine during and after anesthesia. Macroscopic examination at 48 hours revealed durable adherence with no indications of hemorrhage. Histological evaluations highlighted SBP's role in stable clot formation, fibrinogenesis, and tissue regeneration, indicating its potential as a multimodal wound dressing. Although promising, the study has limitations, emphasizing the need for future research with larger samples and controls. This work sets the stage for exploring SBP's clinical implications, particularly in scenarios where lightweight, multimodal technologies are crucial for addressing traumatic injuries and enhancing military medical capabilities.

Rethinking Prehospital Response to Mass Casualty Events: Move, Treat, and Transport.

Herein, we present a simplified approach to prehospital mass casualty event (MASCAL) management called "Move, Treat, and Transport." Prior publications demonstrate a disconnect between MASCAL response training and actions taken during real-world incidents. Overly complex algorithms, infrequent training on their use, and chaotic events all contribute to the low utilization of formal triage systems in the real world. A review of published studies on prehospital MASCAL management and a recent series of military prehospital MASCAL responses highlight the need for an intuitive MASCAL management system that accounts for expected resource limitations and tactical constraints. "Move, Treat, and Transport" is a simple and pragmatic approach that emphasizes speed and efficiency of response; considers time, tactics, and scale of the event; and focuses on interventions and evacuation to definitive care if needed.

Limitations of Triage in Military Mass Casualty Response: A Case Series.

INTRODUCTION: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management. METHODS: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated. RESULTS: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit. CONCLUSION: Formal triage systems requiring the use ofdiagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.

Additive value of blood neutrophil gelatinase-associated lipocalin to clinical judgement in acute kidney injury diagnosis and mortality prediction in patients hospitalized from the emergency department.

INTRODUCTION: Acute kidney injury (AKI) is a common complication among hospitalized patients. The aim of this study was to evaluate the utility of blood neutrophil gelatinase-associated lipocalin (NGAL) assessment as an aid in the early risk evaluation for AKI development in admitted patients. METHODS: This is a multicenter Italian prospective emergency department (ED) cohort study in which we enrolled 665 patients admitted to hospital from the ED. RESULTS: Blood NGAL and serum creatinine (sCr) were determined at ED presentation (T0), and at: 6 (T6), 12 (T12), 24 (T24) and 72 (T72) hours after hospitalization. A preliminary assessment of AKI by the treating ED physician occurred in 218 out of 665 patients (33%), while RIFLE AKI by expert nephrologists was confirmed in 49 out of 665 patients (7%). The ED physician's initial judgement lacked sensitivity and specificity, overpredicting the diagnosis of AKI in 27% of the cohort, while missing 20% of those with AKI as a final diagnosis. CONCLUSIONS: Our study demonstrated that assessment of a patient's initial blood NGAL when admitted to hospital from the ED improved the initial clinical diagnosis of AKI and predicted in-hospital mortality. Blood NGAL assessment coupled with the ED physician's clinical judgment may prove useful in deciding the appropriate strategies for patients at risk for the development of AKI.See related commentary by Legrand et al., http://ccforum.com/content/17/2/132.

The accuracy of the olfactory sense in detecting alcohol intoxication in trauma patients.

INTRODUCTION: A common presentation to the emergency department (ED) is the trauma patient with altered sensorium who is presumed to be alcohol intoxicated by physicians based on their olfactory sense. ED physicians may often leave patients suspected of alcohol intoxication aside until the effects wear off, potentially missing trauma as the source of confusion. This often results in delays in diagnosing acute potentially life-threatening injuries in patients with presumed alcohol intoxication. OBJECTIVE: This study aimed to determine the accuracy of a physician's olfactory sense for diagnosing alcohol intoxication. METHODS: Patients suspected of major trauma in the ED underwent an evaluation by the examining physician for alcohol odour and a blood alcohol level. Alcohol intoxication was defined as a serum ethanol level ≥80 mg/100 ml. Data were reported as means with 95% CI or proportions with IQR 25-75%. RESULTS: 151 patients (70% men) were enrolled, with a median age of 45 years (IQR 33-56). The prevalence of alcohol intoxication was 43% (95% CI 35% to 51%). OPERATING CHARACTERISTICS: Physician assessment of alcohol intoxication: sensitivity 84% (95% CI 73% to 92%), specificity 87% (95% CI 78% to 93%), positive likelihood ratio 6.6 (95% CI 3.8 to 11.6), negative likelihood ratio 0.18 (95% CI 0.1 to 0.3) and accuracy 86% (95% CI 80% to 91%). 7.3% (95% CI 4% to 13%) of patients were falsely suspected of being intoxicated. CONCLUSIONS: Although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in significant numbers of non-intoxicated trauma patients.

The impact of COVID-19 on Diabetic Ketoacidosis patients.

BACKGROUND AND AIM: Describe the prevalence/outcomes of Diabetic Ketoacidosis (DKA) patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods. METHODS: Retrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients that takes place in Eleven hospitals of New York City Health & Hospitals. Our included participants during the pandemic period were admitted COVID-19+ patients (>18 years) and during the pre-pandemic period were admissions (>18 years) selected through the medical record. We excluded transfers during both periods. The intervention was COVID-19+ by PCR testing. The main outcome measured was mortality during the index hospitalization and secondary outcomes were demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (>0.4 mmol/L) and bicarbonate (<15 mmol/L) or pH (<7.3). RESULTS: Demographics and past medical histories were similar during the pre-pandemic (n = 6938) vs. pandemic (n = 7962) periods. DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p > 0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p < 0.001). Surviving vs. non-surviving DKA/COVID-19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0-4.5) (p < 0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2-3.1) (p < 0.001). CONCLUSIONS: COVID-19 increased the prevalence of DKA with higher mortality rates secondary to COVID-19 severity, not DKA. We suggest DKA screening all COVID-19+ patients and prioritizing ICU DKA/COVID-19+ with low oxygen saturation, blood pressures, or renal insufficiency.

The Role of Whole Blood Transfusions in Civilian Trauma: A Review of Literature in Military and Civilian Trauma.

Resuscitation techniques for the management of adult trauma patients have evolved over the 20th century. Whole blood transfusions were previously used as the standard of care, whereas blood component therapy is the current method employed across most trauma centers across the United States. Prior to the transition, no studies were conducted to show improved efficacy of hemostatic potential in trauma patients. Recent conflicts in Iraq and Afghanistan have challenged the dogma that whole blood transfusions are not the standard of care and have shown potential as the superior transfusion product for adult trauma patients. The purpose of this review is to provide a comprehensive review and elucidate if whole blood transfusions have a role in civilian trauma patients based upon recent military medical literature and civilian pilot studies using whole blood transfusions.

Computed tomography angiography for aerodigestive injuries in penetrating neck trauma: A systematic review.

OBJECTIVES: Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? METHODS: Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS-2. RESULTS: Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. CONCLUSION: CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury.

Rationale and Implementation of a Novel Special Operations Medical Officer Course.

BACKGROUND: The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. METHODS: The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. RESULTS: Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. DISCUSSION: For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. CONCLUSION: This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Prehospital Iliac Crest Intraosseous Whole Blood Infusion.

Low-titer cold-stored O-positive whole blood (LTCSO+WB) resuscitation therapy is the cornerstone of military hemorrhagic shock resuscitation. During the past 19 years, improved patient outcomes have shown the importance of this intervention in shock treatment. Iliac crest intraosseous (IO) placement is an alternative when peripheral sites such as the humeral head and tibia are not available options. To date, no study has explored the administration of LTCSO+WB through an iliac crest IO in the military prehospital setting. Contingency procedures for vascular access are necessary for casualties with severe trauma to all four extremities, and the iliac crest is a viable option. The literature supports situational advantages over other peripheral IO sites.

Immediate ß-blockade in patients with myocardial infarctions: is there evidence of benefit?

STUDY OBJECTIVE: The American Heart Association recommends the initiation of ß-blockade to all patients with an ST-segment elevation myocardial infarction (STEMI) without contraindications to ß-blocking agents. The present study seeks to systematically review the medical literature to determine the efficacy of treating STEMI patients with a ß-blocker within the first 24 hours. METHODS: We searched databases for articles through MEDLINE with the PubMed interface and from 1966 through May 2009 and EMBASE from 1980 to August 2009 with the Ovid Technologies interface, using a search strategy derived from the following PICO (Patient-Intervention-Comparator-Outcome) clinical question: In patients presenting with STEMI (P), does immediate treatment with ß-blockers (I) followed by standardized care beginning on day 2 or 3 compared with placebo or no treatment followed by standardized care on day 2 or 3 (C) reduce the risk of death, reinfarction, or cardiogenic shock (O)? The methodological quality of the studies was assessed. RESULTS: From more than 2,000 references identified in the search, only a single randomized trial met the inclusion criteria. There were no statistically significant differences in mortality; the relative risk for the combined endpoint (mortality and reinfarction) was 0.67 (95% confidence interval 0.44 to 1.03) at 6 days and 0.74 (95% confidence interval 0.53 to 1.06) at 6 weeks. Outcomes for cardiogenic shock were not reported. CONCLUSION: Evidence from a single randomized trial failed to demonstrate a reduction in mortality or reinfarction with administration of ß-blocker within the first 24 hours after STEMI.

Routine testing in patients with asymptomatic elevated blood pressure in the ED.

STUDY OBJECTIVE: There are no clear recommendations for the diagnostic evaluation of patients who present to the emergency department (ED) with asymptomatic elevated blood pressure. In patients presenting with asymptomatic elevated blood pressure in the ED, we measured the prevalence of abnormalities on a basic metabolic profile (BMP) that led to hospital admission as well as the prevalence of diminished renal function. METHODS: This is a cross-sectional study at 2 urban teaching EDs with a largely African American population. Adult patients (> or = 18 years) with a triage diastolic blood pressure (BP) 100 mm Hg or higher and without symptoms suggestive of acute end-organ damage were enrolled. All patients had a BMP sent. The primary outcome measured was abnormalities on the BMP that led to hospital admission. The secondary outcome measured was the prevalence of diminished renal function (glomerular filtration rate <60 mL min(-1) 1.73 m(-2)). RESULTS: One hundred sixty-seven patients with asymptomatic elevated BP were studied. Twelve (7.2%; 95% confidence interval, 3%-11%) patients were admitted due to abnormal results on the BMP. Twenty-seven (16.2%; 95% confidence interval, 11%-21%) patients met the secondary outcome measure of diminished renal function (glomerular filtration rate <60 mL min(-1) 1.73 m(-2)). CONCLUSION: In a homogenous African American population presenting to the ED with asymptomatic elevated BP, there is a relatively high prevalence of abnormalities on the BMP that led to hospital admission. We suggest routine testing of a serum creatinine should be strongly considered in a largely African American patient population with asymptomatic elevated BP in the ED.

Triage hyperglycemia as a prognostic indicator of major trauma.

BACKGROUND: To test the diagnostic utility of the triage serum glucose in differentiating major from minor injuries. METHODS: Prospective database at Kings County Hospital, a Level I trauma center, from August 2005 to August 2008. INCLUSION CRITERIA: trauma patients 13+ years. EXCLUSION CRITERIA: diabetes or obvious life-threatening injuries requiring immediate surgery, isolated head trauma, or transferred or dead on arrival. We recorded age, sex, injury mechanism, base deficit (BD), lactate (LAC), and serum glucose and calculated Injury Severity Scores. Major injury: a change in hematocrit >10, blood transfused within 24 hours, or Injury Severity Score >15. Data were reported as mean differences (95% confidence interval [CI]). Groups were compared by Student's t test; receiver operator characteristic curves were compared by Wilcoxon test (two-tailed, [alpha] = 0.05). RESULTS: One thousand six hundred forty-nine patients with an average age of 35.5 years (13-95 years), 79.5% male, and 50% blunt trauma were studied. Patients with major (n = 278) compared with minor injury (n = 1371) had significantly (p < 0.0001) lower BD and higher LACs (p < 0.0001). Major injury patients had significantly (p < 0.0001) higher serum glucose levels (8.33 mMol/L, 95% CI: 7.94-8.69 mMol/L) compared with patients with minor injuries (6.49 mMol/L, 95% CI: 6.39-6.66 mMol/L). Areas under the curve for glucose (0.73, 95% CI: 0.70-0.76) are similar to BD (0.72, 95% CI: 0.68-0.76) and LAC (0.71, 95% CI: 0.67-0.75). CONCLUSIONS: Serum glucose was as discriminating as BD or LAC in differentiating minor from major injury. An initial glucose >/=11.1 mMol/L had a low sensitivity (15%) but a high specificity (94%) for major injury.