Identification and management of low-risk isolated traumatic brain injury patients initially treated at a rural level IV trauma center.

STUDY OBJECTIVE: Our goal was to determine if low-risk, isolated mild traumatic brain injury (TBI) patients who were initially treated at a rural emergency department may have been safely managed without transfer to the tertiary referral trauma center. METHODS: This was a retrospective observational analysis of isolated mild TBI patients who were transferred from a rural Level IV Trauma Center to a regional Level I Trauma Center between 2018 and 2022. Patients were risk-stratified according to the modified Brain Injury Guidelines (mBIG). Data abstracted from the electronic medical record included patient presentation, management, and outcomes. RESULTS: 250 patients with isolated mild TBI were transferred out to the Level I Trauma Center. Fall was the most common mechanism of injury (69.2%). 28 patients (11.2%) were categorized as low-risk (mBIG1). No mBIG1 patients suffered a progression of neurological injury, had worsening of intracranial hemorrhage on repeat head CT, or required neurosurgical intervention. 12/28 (42.9%) of mBIG1 patients had a hospital length of stay of 2 days or less, typically for observation. Those with longer lengths of stay were due to medical complications, such as sepsis, or difficulty in arranging disposition. CONCLUSION: We propose that patients who meet mBIG1 criteria may be safely observed without transfer to a referral Level I Trauma Center. This would be of considerable benefit to patients, who would not need to leave their community, and would improve resource utilization in the region.

Ramipril for the Treatment of COVID-19: RAMIC, a Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

INTRODUCTION: Retrospective studies report that angiotensin-converting enzyme inhibitors (ACEIs) may reduce the severity of COVID-19, but prospective data on de novo treatment with ACEIs are limited. The RAMIC trial was a randomized, multicenter, placebo-controlled, double-blind, allocation-concealed clinical trial to examine the efficacy of de novo ramipril versus placebo for the treatment of COVID-19. METHODS: Eligible participants were aged 18 years and older with a confirmed diagnosis of SARS-CoV-2 infection, recruited from urgent care clinics, emergency departments, and hospital inpatient wards at eight sites in the USA. Participants were randomly assigned to daily ramipril 2.5 mg or placebo orally in a 2:1 ratio, using permuted block randomization. Analyses were conducted on an intention-to-treat basis. The primary outcome was a composite of mortality, intensive care unit (ICU) admission, or invasive mechanical ventilation by day 14. RESULTS: Between 27 May 2020 and 19 April 2021, a total of 114 participants (51% female) were randomized to ramipril (n = 79) or placebo (n = 35). The overall mean (± SD) age and BMI were 45 (± 15) years and 33 (± 8) kg/m2. Two participants in the ramipril group required ICU admission and one died, compared with none in the placebo group. There were no significant differences between ramipril and placebo in the primary endpoint (ICU admission, mechanical ventilation, or death) (3% versus 0%, p = 1.00) or adverse events (27% versus 29%, p = 0.82). The study was terminated early because of a low event rate and subsequent Emergency Use Authorization of therapies for COVID-19. CONCLUSION: De novo ramipril was not different compared with placebo in improving or worsening clinical outcomes from COVID-19 but appeared safe in non-critically ill patients with COVID-19. TRIAL REGISTRATION: Clinicaltrials.gov NCT04366050.

Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department.

INTRODUCTION: Low tidal-volume ventilation (LTVV), defined as a maximum tidal volume of 8 milliliters per kilogram (mL/kg) of ideal body weight, is a key component of lung protective ventilation. Although emergency department (ED) initiation of LTVV has been associated with improved outcomes, disparities in LTVV application exist. In this study our aim was to evaluate whether rates of LTVV are associated with demographic and physical characteristics in the ED. METHODS: We conducted a retrospective observational cohort study using a dataset of patients who underwent mechanical ventilation at three EDs in two health systems from January 2016-June 2019. Demographic, mechanical ventilation, and outcome data including mortality and hospital-free days were abstracted by automatic query. A LTVV approach was defined as a tidal volume ≤8 mL/kg ideal body weight. We performed descriptive statistics and univariate analysis as indicated, and created a multivariate logistic regression model. RESULTS: Of 1,029 patients included in the study, 79.5% received LTVV. Tidal volumes of 400-500 mL were used in 81.9% of patients. Approximately 18% of patients had tidal volumes changed in the ED. Female gender (adjusted odds ratio [aOR] 4.17, P< 0.001), obesity (aOR 2.27, P< 0.001), and first-quartile height (aOR 12.2, P < 0.001) were associated with receiving non-LTVV in multivariate regression analysis. Hispanic ethnicity and female gender were associated with first quartile height (68.5%, 43.7%, P < 0.001 for all). Hispanic ethnicity was associated with receiving non-LTVV in univariate analysis (40.8% vs 23.0%, P < 0.001). This relationship did not persist in sensitivity analysis controlling for height, weight, gender, and body mass index. Patients who received LTVV in the ED had 2.1 more hospital-free days compared to those who did not (P = 0.040). No difference in mortality was observed. CONCLUSION: Emergency physicians use a narrow range of initial tidal volumes that may not meet lung-protective ventilation goals, with few corrections. Female gender, obesity, and first-quartile height are independently associated with receiving non-LTVV in the ED. Using LTVV in the ED was associated with 2.1 fewer hospital-free days. If confirmed in future studies, these findings have important implications for achieving quality improvement and health equality.

Use of sotrovimab in vaccinated versus unvaccinated COVID-19 patients in a resource-limited emergency department during the omicron surge.

Objective: The treatment of outpatient COVID-19 patients at high risk of disease progression has been challenging, as both the virus and available therapeutics change. Here, we sought to evaluate the effect of vaccination status on the use of sotrovimab during the early phase of the Omicron surge. Methods: This was a retrospective observational study performed at El Centro Regional Medical Center, a rural hospital on the southern Californian border. The electronic medical record was queried for all emergency department (ED) patients who received an infusion of sotrovimab between January 6 and February 6, 2022. We obtained patient demographics, COVID-19 vaccination status, medical comorbidities, and whether patients returned to the ED within 30 days. We stratified our cohort according to vaccination status and performed a multivariable logistic regression model to evaluate the relationship between these factors. Results: One hundred seventy patients received an infusion of sotrovimab in the ED. The patient cohort had a median age of 65 years, 78.2% were Hispanic, and obesity (63.5%) was the most common comorbidity. A total of 73.5% of patients were vaccinated against COVID-19. A total of 12/125 (9.6%) of vaccinated patients returned to the ED within 30 days, versus 10/45 (22.2%) in the unvaccinated cohort, which was statically significant (P = 0.03). The presence of medical comorbidities was not associated with the primary outcome. Conclusion: Of patients who received sotrovimab, those who were vaccinated were less likely to return to the ED within 30 days compared to those who were unvaccinated. Given the effectiveness of the COVID-19 vaccination campaign, and with the emergence of new variants, it is unclear what role monoclonal antibody therapy should play in the treatment of outpatient COVID-19 patients.

ICU Admission Risk Factors for Latinx COVID-19 Patients at a U.S.-Mexico Border Hospital.

OBJECTIVE: Few studies have examined the impact of coronavirus disease 2019 (COVID-19) on the primarily Latinx community along the U.S.-Mexico border. This study explores the socioeconomic impacts which contribute to strong predictors of severe COVID-19 complications such as intensive care unit (ICU) hospitalization in a primarily Latinx/Hispanic U.S.-Mexico border hospital. METHODS: A retrospective, observational study of 156 patients (≥ 18 years) Latinx/Hispanic patients who were admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at a U.S.-Mexico border hospital from April 10, 2020, to May 30, 2020. Descriptive statistics of sex, age, body mass index (BMI), and comorbidities (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease). Multivariate regression models were produced from the most significant variables and factors for ICU admission. RESULTS: Of the 156 hospitalized Latinx patients, 63.5% were male, 84.6% had respiratory failure, and 45% were admitted to the ICU. The average age was 67.2 (± 12.2). Those with body mass index (BMI) ≥ 25 had a higher frequency of ICU admission. Males had a 4.4 (95% CI 1.58, 12.308) odds of ICU admission (p = 0.0047). Those who developed acute kidney injury (AKI) and BMI 25-29.9 were strong predictors of ICU admission (p < 0.001 and p = 0.0020, respectively). Those with at least one reported comorbidity had 1.98 increased odds (95% CI 1.313, 2.99) of an ICU admission. CONCLUSION: Findings show that age, AKI, and male sex were the strongest predictors of COVID-19 ICU admissions in the primarily Latinx population at the U.S.-Mexico border. These predictors are also likely driven by socioeconomic inequalities which are most apparent in border hospitals.

Bamlanivimab Reduces ED Returns and Hospitalizations and May Reduce COVID-19 Burden on Low-resource Border Hospitals.

INTRODUCTION: To evaluate the effectiveness of bamlanivimab at reducing return emergency department (ED) visits in primarily Latinx/Hispanic patients with mild or moderate coronavirus disease 2019 (COVID-19). Secondary aims were to evaluate the prevention of subsequent hospitalizations and deaths in a resource-limited United States (U.S.)-Mexico border hospital. METHODS: We conducted a retrospective, open-label interventional study on 270 eligible adult patients diagnosed with mild-moderate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who met criteria for receiving bamlanivimab from November 1, 2020 to January 31, 2021. The main outcomes of 14-day return visits to the ED and hospitalizations due to COVID-19 were compared between two groups - those who received bamlanivimab (exposed group) and those who did not receive bamlanivimab (unexposed group). Outcomes were analyzed through chi-square tests followed by multivariate regression modeling to adjust for patient demographics, characteristics, and comorbidities. RESULTS: There were 136 COVID-19 patients who received bamlanivimab in the ED prior to discharge and an unexposed group of 134 COVID-19 patients who were evaluated and discharged from the ED without receiving bamlanivimab. Overall, mean age was 61.7 (S.D. +/-13.9) years, mean body mass index (BMI) 31.0 (S.D. +/-6.6) kg/m2, 91.5% identified as Latinx/Hispanic, 51.9% male, and 80.7% reported at least one comorbidity. Most commonly reported comorbidities were obesity (22.6%), hypertension (59.6%), and diabetes (41.1%). The bamlanivimab group had a 22.8% (mean estimate = 0.7717, 95% CI [0.6482, 0.8611]) risk reduction or 84.4% (0.3030, 95% CI = 0.166, 0.554, p=.0001) absolute reduction of ED return visits within 14 days compared to controls after adjusting for chronic kidney disease. The bamlanivimab group had 19.0% (mean estimate=0.8097, 95% CI [0.6451, 0.9087]) risk reduction or 96.2% (0.235, 95% CI 0.100, 0.550, p=0.0008) absolute reduction of subsequent hospitalizations compared to unexposed patients after adjusting for diabetes status. CONCLUSION: Bamlanivimab infusions for high-risk COVID-19 patients in the ED substantially reduced the risk of return visits to the ED and hospitalizations in our primarily Latinx/Hispanic population. Monoclonal antibody infusions may help reduce hospital utilization during COVID-19 surges at U.S.-Mexico border hospitals.

An Immaculate Deception: Persistently Elevated Serum ß-Hcg in Metastatic Signet Ring Cell Gastric Adenocarcinoma.

BACKGROUND: Persistent elevations in beta-human chorionic gonadotropin (ß-hCG) can be an ominous sign of both trophoblastic and non-trophoblastic malignancies. The absence of a clearly identified etiology of ß-hCG elevation warrants pursuit of further diagnostic testing to determine the source of ectopic ß-hCG. CASE REPORT: A virginal 26-year-old woman with past medical history significant for persistently elevated ß-hCG presented to our Emergency Department with shortness of breath, pleuritic chest pain, nausea, and vomiting, and was found to have widely metastatic gastric signet ring cell adenocarcinoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although elevated serum ß-hCG is a generally a marker of pregnancy, ß-hCG elevation without clear etiology necessitates ruling out other insidious processes. Failure to maintain and pursue a broad differential in the context of unexplained elevations of ß-hCG can result in catastrophic missed or delayed diagnosis.

Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale.

OBJECTIVES: The Clinical Opiate Withdrawal Scale (COWS) is a validated, commonly used tool to objectively quantify withdrawal symptoms, often in anticipation of treatment with buprenorphine. Our primary aim was to determine the agreement between emergency department (ED) nurses compared with emergency physicians in determining this score in ED patients who presented for opioid withdrawal treatment. Secondarily, we wanted to investigate the safety of buprenorphine induction in the ED setting. METHODS: Scoring for opioid withdrawal using the COWS was performed by ED clinicians and ED nurses independently on 120 patients. In addition to overall concordance, agreement (weighted kappa) was calculated between the 2 scores by various cutoffs: overall severity, COWS ≥ 5, and the 11 different individual measures. Patient documents also were reviewed for complications that could be possibly linked to buprenorphine induction. RESULTS: Our study sample of 120 subjects was 77% Hispanic and 78.3% male. The clinicians assigned a median interquartile range overall COWS score of 6 (2-12), which categorizes as mild withdrawal. Seventy-eight (65%) subjects met the criteria of withdrawal (≥ 5 COWS) and 69 (58%) received an induction dose of buprenorphine (range 2 mg-24 mg) during the ED visit. No adverse effects or worsening withdrawal were reported. The overall observed concordance, based on severity withdrawal categorization, for all clinician pairs, was 67.5% (81/120) (95% confidence interval [CI], 58.7-75.2%). The weighted kappa for that concordance was 0.55 (95% CI, 0.43-0.67), giving a moderate strength of agreement. When data are dichotomized by COWS score ≥5, concordance was 82.5% (99/120) (95% CI, 74.7%-88.3%) and the weighted kappa was 0.65 (95% CI, 0.51-0.78), indicating substantial agreement. The breakdown by the 11 factors that constitute COWS showed only substantial agreement for pulse measurement. CONCLUSION: The agreement between ED clinicians and nurses for the overall COWS scoring in patients presenting for opioid withdrawal treatment was substantial. COWS scoring by ED nurses may help expedite treatment with buprenorphine on presentation.

Outcomes for in-hospital cardiac arrest for COVID-19 patients at a rural hospital in Southern California.

BACKGROUND: In-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California. METHODS: Single-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition. RESULTS: Twenty-one patients were identified, most of whom were Hispanic, male, and aged 50-70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged. CONCLUSION: At a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings.

A BERIBERI UNHEALTHY LATTE: ENCEPHALOPATHY AND SHOCK FROM SEVERE NUTRITIONAL DEFICIENCY.

BACKGROUND: Thiamine deficiency is an uncommon cause of severe illness in the United States that can lead to significant morbidity because of high-output cardiac failure, peripheral neuropathy, and permanent neurologic impairment. We report the case of a middle-aged woman with extreme malnutrition caused by complications of Roux-en-Y gastric bypass (RYGB) surgery who presented with signs and symptoms of severe thiamine deficiency and septic shock. CASE REPORT: A 43-year-old woman who had undergone RYGB surgery and who had multiple complications presented to the emergency department with agitation, confusion, and lethargy. The physical examination revealed an obtunded woman appearing much older than her reported age with significant peripheral edema. She was hypoxemic, hypotensive, and febrile. The initial laboratory analysis revealed a serum lactate level above the measurable limit, a normal thyroid-stimulating hormone, and elevated levels of troponin and brain natriuretic peptide. A transthoracic echocardiogram showed high-output heart failure. The patient's family later revealed that for the past year her diet had consisted almost exclusively of frozen blended lattes. High doses of thiamine and folate were started. Her shock, hyperlactatemia, and respiratory failure resolved by hospital day 3 and her encephalopathy resolved soon thereafter. Why Should an Emergency Physician be Aware of This?: Thiamine deficiency is a rare but reversible cause of shock, heart failure, and encephalopathy. Identifying patients who are at risk for severe nutritional deficiencies may aid in more rapid treatment with relatively benign medications with little downside, in this case high-dose vitamin B1, and ultimately improve patient-oriented outcomes such as mortality, morbidity, and hospital length of stay.

Large Cerebellar Stroke in a Young COVID-19-Positive Patient: Case Report.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most frequently presents with respiratory symptoms, such as fever, dyspnea, shortness of breath, cough, or myalgias. There is now a growing body of evidence that demonstrates that severe SARS-CoV-2 infections can develop clinically significant coagulopathy, inflammation, and cardiomyopathy, which have been implicated in COVID-19-associated cerebrovascular accidents (CVAs). CASE REPORT: We report an uncommon presentation of a 32-year-old man who sustained a large vessel cerebellar stroke associated with a severe COVID-19 infection. He presented with a headache, worse than his usual migraine, dizziness, rotary nystagmus, and dysmetria on examination, but had no respiratory symptoms initially. He was not a candidate for thrombolytic therapy or endovascular therapy and was managed with clopidogrel, aspirin, and atorvastatin. During hospital admission he developed COVID-19-related hypoxia and pneumonia, but ultimately he was discharged to home rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the growing number of reports of neurologic and vascular complications, such as ischemic CVAs, in otherwise healthy individuals who are diagnosed with SARS-CoV-2 infection. A brief review of the current literature will help elucidate possible mechanisms, risk factors, and current treatments for CVA associated with SARS-CoV-2.

Case Report of Thrombosis of the Distal Aorta with Occlusion of Iliac Arteries in COVID-19 Infection.

INTRODUCTION: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the coronavirus disease of 2019 (COVID-19) pandemic, has been associated with a variety of prothrombotic sequelae. The pathogenesis of this hypercoagulability has not yet been fully elucidated, but it is thought to be multifactorial with overactivation of the complement pathways playing a central role. There is emerging evidence that the resulting complications are not confined to the venous circulation, and even in patients without typical respiratory symptoms or traditional risk factors, there is a significant rate of arterial thromboembolic disease in patients with SARS-CoV-2 infection. CASE REPORT: We describe a patient presenting with bilateral leg pain without any respiratory symptoms or fever who ultimately was found to be COVID-19 positive and had thromboembolism of the aorta and bilateral iliac occlusion. This report reviews available evidence on the prevalence of arterial thromboembolism in COVID-19 patients and some proposed mechanisms of the pathophysiology of COVID-19-associated coagulopathy. CONCLUSION: It is important that the emergency physician maintain a high degree of suspicion for arterial thromboembolic disease in patients who are infected with COVID-19 even in the absence of typical respiratory symptoms. Additionally, COVID-19 should be considered in patients with unexplained thromboembolic disease, as this may increase the detection of COVID-19.