Evaluation of hydroxocobalamin use for the treatment of suspected cyanide toxicity secondary to smoke inhalation.

Hydroxocobalamin is used for cyanide toxicity after smoke inhalation, but diagnosis is challenging. Retrospective studies have associated hydroxocobalamin with acute kidney injury (AKI). This is a retrospective analysis of patients receiving hydroxocobalamin for suspected cyanide toxicity. The primary outcome was the proportion of patients meeting predefined appropriate use criteria defined as ≥1 of the following: serum lactate ≥8 mmol/L, systolic blood pressure (SBP) <90 mmHg, new-onset seizure, cardiac arrest, or respiratory arrest. Secondary outcomes included incidence of AKI, pneumonia, resolution of initial neurologic symptoms, and in-hospital mortality. Forty-six patients were included; 35 (76%) met the primary outcome. All met appropriate use criteria due to respiratory arrest, 15 (43%) for lactate, 14 (40%) for SBP, 12 (34%) for cardiac arrest. AKI, pneumonia, and resolution of neurologic symptoms occurred in 30%, 21%, and 49% of patients, respectively. In-hospital mortality was higher in patients meeting criteria, 49% vs. 9% (95% CI 0.16, 0.64). When appropriate use criteria were modified to exclude respiratory arrest in a post-hoc analysis, differences were maintained, suggesting respiratory arrest alone is not a critical component to determine hydroxocobalamin administration. Predefined appropriate use criteria identify severely ill smoke inhalation victims and provides hydroxocobalamin treatment guidance.

Epidemiology and healthcare utilization for rectal foreign bodies in United States adults, 2012-2021.

INTRODUCTION: Presentations to the emergency department for rectal foreign bodies are common, but there is little epidemiologic information on this condition. This limits the ability to provide evidence-based education to trainees regarding the populations affected, the types and frequency of foreign bodies, and factors associated with hospitalization. To address this, we analyzed national estimates of emergency department presentations for rectal foreign bodies from 2012 to 2021 in the US. METHODS: We queried the National Electronic Injury Surveillance System for any injury to the 'pubic region' or 'lower trunk' with an accompanying diagnosis of foreign body, puncture, or laceration. Two authors manually reviewed all clinical narratives to identify cases of rectal foreign bodies. National estimates were determined using weighting and strata variables, incidence rates calculated using census data, trends assessed by linear regression, and factors associated with hospitalization identified by multivariable logistic regression. RESULTS: From 885 cases, there were an estimated 38,948 (95% CI, 32,040-45,856) emergency department visits for rectal foreign bodies among individuals ≥15 years from 2012 to 2021. The average age was 43, 77.8% were male, 55.4% of foreign bodies were sexual devices, and 40.8% required hospitalization. The annual incidence of presentations for rectal foreign bodies increased from 1.2 in 2012 to 1.9 per 100,000 persons in 2021 (R2 = 0.84, p < 0.01). Males have a bimodal age distribution peaking in the fifth decade, while females have a right-skewed age distribution peaking in the second decade. Female sex (odds ratio [OR] 0.4; 95% confidence interval [CI], 0.2-0.6) and, compared to sexual devices, balls/marbles (OR 0.2; 95% CI, 0.05-0.6) or drugs/paraphernalia (OR 0.1; 95% CI, 0.05-0.4) are associated with a reduced odds of hospitalization. CONCLUSIONS: Presentations to the emergency department for rectal foreign bodies increased for males and females from 2012 to 2021 in the United States. These epidemiologic estimates for a complex form of anorectal trauma provide preclinical information for emergency medicine, surgery, and radiology trainees.

Evaluation of fixed-dose versus variable-dose prothrombin complex concentrate for warfarin reversal.

INTRODUCTION: The purpose was to compare hemostatic efficacy rates for fixed- and variable-dose four-factor prothrombin complex concentrate (4F-PCC) for warfarin reversal. MATERIAL AND METHODS: Retrospective study of patients with non-intracranial major bleeding or undergoing emergent surgery/procedure who received 4F-PCC for warfarin reversal from September 2013 through August 2020. Hemostatic efficacy at 48 h following fixed- or variable-dose 4F-PCC was evaluated using modified International Society on Thrombosis and Hemostasis (ISTH) criteria for major bleeding. Secondary outcomes included occurrence of post-4F-PCC INR ≤ 1.5, in-hospital mortality, time to 4F-PCC administration, and 4F-PCC cost. Univariate analyses were completed and logistic regression used to identify patient-specific factors associated with hemostatic efficacy. RESULTS: A total of 265 patients, 90 (34%) fixed- and 175 (66%) variable-dose 4F-PCC, were included. Hemostatic efficacy was achieved in 34 (37.8%) and 38 (21.7%) in fixed- and variable-dose groups, respectively, p = 0.005. Achievement of INR ≤ 1.5 occurred in 55 (62.5%) in the fixed- and 120 (69.4%) in the variable-dose groups, p = 0.26, and there was no in-hospital mortality difference. Time to administration was a mean 20 min faster and cost was reduced by a mean $1881/dose in the fixed-dose group. The unadjusted odds of achieving hemostatic efficacy was 2.27 among those receiving fixed-dose compared to variable-dose 4F-PCC (95% CI 1.30, 3.98); this was not confounded by initial INR or patient weight. CONCLUSION: Fixed-dose 4F-PCC is associated with a higher likelihood of achieving hemostatic efficacy, quicker time to administration, and reduced cost compared to variable-dose 4F-PCC for warfarin reversal.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review.

PURPOSE: To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology. METHODS: A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded. RESULTS: The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I2 = 63.9% and 72.9%, respectively). CONCLUSIONS: Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Machine learning-assisted screening for cognitive impairment in the emergency department.

BACKGROUND/OBJECTIVES: Despite a high prevalence and association with poor outcomes, screening to identify cognitive impairment (CI) in the emergency department (ED) is uncommon. Identification of high-risk subsets of older adults is a critical challenge to expanding screening programs. We developed and evaluated an automated screening tool to identify a subset of patients at high risk for CI. METHODS: In this secondary analysis of existing data collected for a randomized control trial, we developed machine-learning models to identify patients at higher risk of CI using only variables available in electronic health record (EHR). We used records from 1736 community-dwelling adults age > 59 being discharged from three EDs. Potential CI was determined based on the Blessed Orientation Memory Concentration (BOMC) test, administered in the ED. A nested cross-validation framework was used to evaluate machine-learning algorithms, comparing area under the receiver-operator curve (AUC) as the primary metric of performance. RESULTS: Based on BOMC scores, 121 of 1736 (7%) participants screened positive for potential CI at the time of their ED visit. The best performing algorithm, an XGBoost model, predicted BOMC positivity with an AUC of 0.72. With a classification threshold of 0.4, this model had a sensitivity of 0.73, a specificity of 0.64, a negative predictive value of 0.97, and a positive predictive value of 0.13. In a hypothetical ED with 200 older adult visits per week, the use of this model would lead to a decrease in the in-person screening burden from 200 to 77 individuals in order to detect 10 of 14 patients who would fail a BOMC. CONCLUSION: This study demonstrates that an algorithm based on EHR data can define a subset of patients at higher risk for CI. Incorporating such an algorithm into a screening workflow could allow screening efforts and resources to be focused where they have the most impact.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

OBJECTIVE: We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS: We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS: We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS: Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.