Point-of-Care-Ultrasound Quality Assurance Data from Fellow-Performed Exams in a Pediatric Emergency Department: A Descriptive Study.

OBJECTIVES: Point-of-care-ultrasound (POCUS) is increasingly used by pediatric emergency medicine (PEM) fellows, but scant data exists on the accuracy of exam interpretations. Our goal was to determine whether agreement on exam interpretation between quality assurance (QA) faculty (reference standard) and PEM fellows varied by fellowship year or exam type. METHODS: Retrospective review of fellow-performed POCUS exams between January 2019 and June 2022. Negative binomial (NB) random effects regression was used to account for longitudinal measurement of individual fellow performance across 3 years. Fixed effects were exam type and fellowship year. To assess between- and within-user variability across time, a random intercept and slope were included for each fellow. RESULTS: Exactly 3032 exams, performed by 24 fellows, were included. Raw proportion agreement by fellowship year was high for all exam types (≥88%). From the NB model, there was no statistically significant effect of fellowship year on the mean count of agreement. The relative risk (RR) of agreement for exam types was greatest for cardiac vs other types. The standard deviations for the random intercept and random slope were 0.09 and 0.04, respectively, with a correlation of -0.94. CONCLUSIONS: PEM fellows generally interpret exams correctly, with little variation through fellowship, although those who began with more basic skills showed more progress over time. Fellowship year did not influence the likelihood of correct interpretation but there was variation across exam type, with the best agreement for cardiac exams. The extent to which disagreements between fellows and QA faculty represent clinically significant errors requires further study.

Right ventricular dysfunction in acute heart failure from emergency department to discharge: Predictors and clinical implications.

BACKGROUND: Among acute heart failure (AHF) inpatients, right ventricular dysfunction (RVD) predicts clinical outcomes independent of left ventricular (LV) dysfunction. Prior studies have not accounted for congestion severity, show conflicting findings on echocardiography (echo) timing, and excluded emergency department (ED) patients. We describe for the first time the epidemiology, predictors, and outcomes of RVD in AHF starting with earliest ED treatment. METHODS: Point-of-care echo and 10-point lung ultrasound (LUS) were obtained in 84 prospectively enrolled AHF patients at two EDs, ≤1 h after first intravenous diuresis, vasodilator, and/or positive pressure ventilation (PPV). Echo and LUS were repeated at 24, 72, and 168 h, unless discharged sooner (n = 197 exams). RVD was defined as <17 mm tricuspid annulus plane systolic excursion (TAPSE), our primary measure. To identify correlates of RVD, a multivariable linear mixed model (LMM) of TAPSE through time was fit. Possible predictors were specified a priori and/or with p ≤ 0.1 difference between patients with/without RVD. Data were standardized and centered to facilitate comparison of relative strength of association between predictors of TAPSE. Survival curves for a 30-day death or AHF readmission primary outcome were assessed for RVD, LUS severity, and LVEF. A multivariable generalized linear mixed model (GLMM) for the outcome was used to adjust RVD for LVEF and LUS. RESULTS: 46% (n = 39) of patients at ED arrival showed RVD by TAPSE (median 18 mm, interquartile range 13-23). 18 variables with p ≤ 0.1 unadjusted difference with/without RVD, and 12 a priori predictors of RVD were included in the multivariable LMM model of TAPSE through time (R2 = 0.76). Missed antihypertensive medication (within 7 days), ED PPV, chronic obstructive pulmonary disease history, LVEF, LUS congestion severity, and right ventricular systolic pressure (RVSP) were the strongest multivariable predictors of RVD, respectively, and the only to reach statistical significance (p < 0.05). 30-day death or AHF readmission was associated with RVD at ED arrival (hazard ratio {HR} 3.31 {95%CI: 1.28-8.53}, p = 0.009), ED to discharge decrease in LUS (HR 0.11 {0.01-0.85}, p < 0.0001 for top quartile Δ), but not LVEF (quartile 2 vs. 1 HR 0.78 {0.22-2.68}, 3 vs. 1 HR 0.55 {0.16-1.92}, 4 vs. 1 HR 0.32 {0.09-1.22}, p = 0.30). The area under the receiver operating curve on GLMM for the primary outcome by TAPSE (p = 0.0012), ΔLUS (p = 0.0005), and LVEF (p = 0.8347) was 0.807. CONCLUSION: In this observational study, RVD was common in AHF, and predicted by congestion on LUS, LVEF, RVSP, and comorbidities from ED arrival through discharge. 30-day death or AHF-rehospitalization was associated with RVD at ED arrival and ΔLUS severity, but not LVEF.

Do septic patients with reduced left ventricular ejection fraction require a low-volume resuscitative strategy?

BACKGROUND: Many clinicians are wary of administering 30 cc/kg of intravenous fluid (IVF) to septic patients with reduced left-ventricular ejection fraction (rLVEF), fearing volume overload. Prior studies have used history of heart failure, rather than LVEF measured at presentation, thereby potentially distorting the relationship between rLVEF, IVF, and adverse outcomes. Our goal was to assess the relationship between IVF volume and outcomes in patients with, versus without, rLVEF. METHODS: This was a prospective observational study performed at an urban Emergency Department (ED). Included patients were adults with suspected sepsis, defined as being treated for infection plus either systolic blood pressure <90 mm/Hg or lactate >2 mmol/L. All patients had LVEF assessed by ED echocardiogram, prior to receipt of >1 l IVF. MEASUREMENTS AND MAIN RESULTS: We enrolled 73 patients, of whom 33 had rLVEF, defined as <40%. Patients with rLVEF were older, had greater initial lactate, more ICU admission, and more vasopressor use. IVF volume was similar between LVEF groups at 3-h (2.2 (IQR 0.8) vs 2.0 (IQR 2.4) liters) while patients with rLVEF were more likely to achieve 30 cc/kg (61% (CI 44-75) vs 45% (CI 31-60). In the reduced versus not-reduced LVEF groups, hospital days, ICU days, and ventilator days were similar: 8 (IQR 7) vs 6.5 (8.5) days, 7 (IQR 7) vs 5 (4) days, and 4 (IQR 8) vs. 5 (10) days, respectively. CONCLUSIONS: Septic patients with rLVEF at presentation received similar volume of IVF as those without rLVEF, without an increase in adverse outcomes attributable to volume overload. While validation is needed, our results suggest that limiting IVF administration in the setting of rLVEF is not necessary.

Primer on Logistic Regression for Emergency Care Researchers.

BACKGROUND: Logistic regression plays a fundamental role in the production of decision rules, risk assessment, and in establishing cause and effect relationships. This primer is aimed at novice researchers with minimal statistical expertise. OBJECTIVE: Introduce the logit equation and provide a hands-on example to facilitate understanding of its benefits and limitations. DISCUSSION: This primer reviews the mathematical basis of a logit equation by comparing and contrasting it with the simple straight-line (linear) equation. After gaining an understanding of the meaning of beta coefficients, readers are encouraged to download a free statistical program and database to produce a logistic regression analysis. Using this example, the narrative then discusses commonly used methods to describe model fitness, including the C-statistic, chi square, Akaike and Bayesian Information Criteria, McFadden's pseudo R2, and the Hosmer-Lemeshow test. The authors provide a how-to discussion for variable selection and estimate of sample size. However, logistic regression alone can seldom establish causal inference without further steps to explore the often complex relationship amongst variables and outcomes, such as with the use of a directed acyclic graphs. We present key elements that generally should be considered when appraising an article that uses logistic regression. This primer provides a basic understanding of the theory, hands-on construction, model analysis, and limitations of logistic regression in emergency care research. CONCLUSIONS: Logistic regression can provide information about the association of independent variables with important clinical outcomes, which can be the first step to show predictiveness or causation of variables on the outcomes of interest. © 2022 Elsevier Inc.

The Parasternal Long Axis View in Isolation: Is it Good Enough?

BACKGROUND: Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination. OBJECTIVE: Our primary goal was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction, and right ventricular (RV) dilatation compared with a four-view FOCUS examination. METHODS: This was a retrospective study looking at FOCUS images. Examinations were blinded and randomized for review by point-of-care ultrasound faculty. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation with findings on a full four-view FOCUS examination, which served as the criterion standard. Sensitivity and specificity were calculated. RESULTS: Of 100 FOCUS examinations; 36% were normal, 16% had a pericardial effusion, 41% had an LV ejection fraction < 50%, and 7% had RV dilatation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction, and RV dilatation were 81% (confidence interval [CI] 0.54-0.95) and 98% (95% CI 0.91-0.99), 100% (95% CI 0.88-1) and 91% (95% CI 0.80-0.97), and 71% (95% CI 0.30-0.94) and 99% (95% CI 0.93-1), respectively. All moderate to large effusions were identified correctly. Overall, there were only four clinically significant disagreements between PSLA alone and the four-view interpretations. CONCLUSIONS: In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.

Risk factors associated with hospital admission in COVID-19 patients initially admitted to an observation unit.

BACKGROUND: No set guidelines to guide disposition decisions from the emergency department (ED) in patients with COVID-19 exist. Our goal was to determine characteristics that identify patients at high risk for adverse outcomes who may need admission to the hospital instead of an observation unit. METHODS: We retrospectively enrolled 116 adult patients with COVID-19 admitted to an ED observation unit. We included patients with bilateral infiltrates on chest imaging, COVID-19 testing performed, and/or COVID-19 suspected as the primary diagnosis. The primary outcome was hospital admission. We assessed risk factors associated with this outcome using univariate and multivariable logistic regression. RESULTS: Of 116 patients, 33 or 28% (95% confidence interval [CI] 20-37%) required admission from the observation unit. On multivariable logistic regression analysis, we found that hypoxia defined as room-air oxygen saturation < 95% (OR 3.11, CI 1.23-7.88) and bilateral infiltrates on chest radiography (OR 5.57, CI 1.66-18.96) were independently associated with hospital admission, after adjusting for age. Two three-factor composite predictor models, age > 48 years, bilateral infiltrates, hypoxia, and Hispanic race, bilateral infiltrates, hypoxia yield an OR for admission of 4.99 (CI 1.50-16.65) with an AUC of 0.59 (CI 0.51-0.67) and 6.78 (CI 2.11-21.85) with an AUC of 0.62 (CI 0.54-0.71), respectively. CONCLUSIONS: Over 1/4 of suspected COVID-19 patients admitted to an ED observation unit ultimately required admission to the hospital. Risk factors associated with admission include hypoxia, bilateral infiltrates on chest radiography, or the combination of these two factors plus either age > 48 years or Hispanic race.

ST Elevation in the COVID-19 Era: A Diagnostic Challenge.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 induces a marked prothrombotic state with varied clinical presentations, including acute coronary artery occlusions leading to ST-elevation myocardial infarction (STEMI). However, while STEMI on electrocardiogram (ECG) is not always associated with acute coronary occlusion, this diagnostic uncertainty should not delay cardiac catheterization. CASE REPORTS: We present 2 cases of patients with COVID-19 that presented with STEMI on ECG. While both patients underwent cardiac catheterization, a delay in time to intervention in the patient found to have acute coronary artery occlusion may have contributed to a poor outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases highlight the fact that while not all COVID-19 patients with STEMI on ECG will have acute coronary artery occlusions, there is continued need for prompt percutaneous coronary intervention during the severe acute respiratory syndrome coronavirus 2 pandemic.

An Asynchronous Curriculum for Teaching Practical Interpretation Skills of Clinical Images to Residents in Emergency Medicine.

BACKGROUND: Interpretation of radiologic images is a critical skill for resident physicians in emergency medicine (EM), however, few training programs offer formal training in this realm. Time and money also need to be considered when adding to the curriculum of trainees. OBJECTIVE: We sought to determine the utilization and benefit of an asynchronous curriculum in the interpretation of diagnostic imaging. METHODS: Radiologic images were obtained from emergency department patients and presented to the trainees on a weekly basis from April to December 2017; discussion questions regarding the images were posed, all via the online workplace platform Slack. Trainees were surveyed prior to and 8 months after initiation of the curriculum to ascertain their confidence with radiologic image interpretation and their use of Slack. RESULTS: Of the 36 potential resident physician participants in this study, 31 (86%) completed the pre-intervention survey and 28 (78%) completed the post-intervention survey. The curriculum was found to be beneficial to all respondents (100%) and increased their confidence with image interpretation from 2.93 ± 0.89 pre-intervention (5-point Likert scale) to 3.46 ± 0.83 post-intervention (p < 0.02). Seventy-five percent noted that they viewed the material "often" or "anytime new material was posted." CONCLUSIONS: Use of an asynchronous curriculum in image interpretation increased the confidence of trainees and was well-utilized. The implications of this are far-reaching, given that a similar intervention could be undertaken for any topic in any specialty in medicine, and with no cost of money or didactic time.

Contrast Extravasation as a Complication of Emergency Nurse-Performed Ultrasound-Guided Peripheral Intravenous Catheter Placement.

INTRODUCTION: Vascular access procedures are among the most commonly performed procedures in the emergency department. The objective of the current study was to compare the contrast extravasation rate for ultrasound-guided peripheral intravenous (USGPIV) catheter placement by emergency nurses with peripheral intravenous catheters placed by standard landmark techniques. METHODS: A retrospective chart review of all ED patients at our urban tertiary-care institution who underwent contrasted computed tomography examination and suffered contrast extravasation events was performed. A logbook of all ED patients who underwent USGPIV placement and an institution-wide electronic patient safety incident-reporting system was reviewed for all contrast extravasation events between May 2014, and February 2017. Data were analyzed using descriptive statistics, Student t-tests for continuous data, and χ2 or Fisher's exact test for categorical data. RESULTS: One thousand five hundred USGPIV catheters were placed by 27 emergency nurses. Contrast material was administered 29,508 times, and, of these, 291 were administered via USGPIV placement. There were 74 peripheral IV lines with documented contrast extravasations (0.25%) as reported in the safety-event database; 12 (4.1%) were from the USGPIV population, and 62 (0.21%) occurred in the standard landmark technique population. Relative risk of contrast extravasation events with USGPIV placement was 19.4 (95% confidence interval [CI], 10.6-35.6), and the absolute risk difference was 3.9% (95% CI 1.6%-6.2%). DISCUSSION: USGPIV placement by trained emergency nurses has higher rates of contrast extravasation than with standard landmark technique placement.

Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature.

BACKGROUND: Sepsis is a common condition encountered by emergency and critical care physicians, with significant costs, both economic and human. Myocardial dysfunction in sepsis is a well-recognized but poorly understood phenomenon. There is an extensive body of literature on this subject, yet results are conflicting and no objective definition of septic cardiomyopathy exists, representing a critical knowledge gap. OBJECTIVES: In this article, we review the pathophysiology of septic cardiomyopathy, covering the effects of key inflammatory mediators on both the heart and the peripheral vasculature, highlighting the interconnectedness of these two systems. We focus on the extant literature on echocardiographic and laboratory assessment of the heart in sepsis, highlighting gaps therein and suggesting avenues for future research. Implications for treatment are briefly discussed. CONCLUSIONS: As a result of conflicting data, echocardiographic measures of left ventricular (systolic or diastolic) or right ventricular function cannot currently provide reliable prognostic information in patients with sepsis. Natriuretic peptides and cardiac troponins are of similarly unclear utility. Heterogeneous classification of illness, treatment variability, and lack of formal diagnostic criteria for septic cardiomyopathy contribute to the conflicting results. Development of formal diagnostic criteria, and use thereof in future studies, may help elucidate the link between cardiac performance and outcomes in patients with sepsis.

A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart Failure.

BACKGROUND: Multiorgan ultrasound (US), which includes evaluation of the lungs and heart, is an accurate method that outperforms clinical gestalt for diagnosing acutely decompensated heart failure (ADHF). A known barrier to ultrasound use is the time needed to perform these examinations. OBJECTIVE: The primary goal of this study was to determine the test characteristics of a modified lung and cardiac US (LuCUS) protocol for the accurate diagnosis of ADHF. METHODS: This was a secondary analysis of a prospective observational study that enrolled adult patients presenting to the emergency department with undifferentiated dyspnea. Intervention consisted of a modified LuCUS protocol performed by experienced emergency physician sonographers. A positive modified LuCUS protocol was defined as the presence of B+ lines in both the left and right anterosuperior lung zones, plus a left ventricular ejection fraction <45%. If all three of these findings were not present, the modified LuCUS result was interpreted as negative for ADHF. The primary objective was measured by comparing US findings to final diagnosis independently determined by two physicians, both blinded to US findings and each other's final diagnosis. RESULTS: We analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the modified LuCUS protocol are 25% (95% confidence interval [CI] 14-41%), 100% (95% CI 94-100%), undefined, and 0.75 (95% CI 0.62-0.91%), respectively. This modified protocol takes on average 1 min and 32 sec to complete. CONCLUSION: The point estimate for the specificity of the modified LuCUS protocol in this pilot study, accomplished by a reanalysis of data collected for a previously reported investigation of the full LuCUS protocol, was 100% for the diagnosis of ADHF.

Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography?

OBJECTIVES: The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist. METHODS: We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations. RESULTS: We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72). CONCLUSION: After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.

Impact of initial high flow nasal cannula flow rates on clinical outcomes in children with bronchiolitis.

PURPOSE: Our aim was to evaluate the impact of the initial high flow nasal cannula (HFNC) flow rate on clinical outcomes in children with bronchiolitis. METHODS: This secondary analysis of retrospective data included children <2 years who required HFNC for bronchiolitis between 10/01/2018-04/20/2019, and following implementation of a revised institutional bronchiolitis pathway between 10/01/2021-04/30/2022. The new pathway recommended weight-based initiation of HFNC at 1.5-2 L/kg/min. We evaluated the effect of low (<1.0 L/kg/min), medium (1-1.5 L/kg/min) and high (>1.5 L/kg/min) HFNC flow rates on need for positive pressure ventilation (PPV), intensive care unit (ICU) transfer, HFNC treatment time, and hospital length of stay (LOS). RESULTS: The majority of the 885 included children had low initial flow rates (low [n = 450, 50.8%], medium [n = 332, 37.5%] and high [n = 103, 11.7%]). There were no significant differences in PPV (high: 7.8% vs. medium: 9.3% vs. low: 8.2%, p = 0.8) or ICU transfers (high: 4.9% vs. medium: 6.0% vs. low: 3.8%, p = 0.3). The low flow group had a significantly longer median HFNC treatment time (High: 29 [18, 45] vs. medium: 29 [16, 50] vs. low: 39 [25, 63], p < .001) and hospital LOS (High: 41 [27, 59] vs. medium: 42 [29, 66] vs. low: 50 (39, 75), p < .001). Logistic and linear regression models did not demonstrate any associations between HFNC flow rates and PPV or hospital LOS. CONCLUSIONS: Initial HFNC flow rates were not associated with significant changes in clinical outcomes in children in children with bronchiolitis.

The prognostic value of improving congestion on lung ultrasound during treatment for acute heart failure differs based on patient characteristics at admission.

BACKGROUND: Lung ultrasound congestion scoring (LUS-CS) is a congestion severity biomarker. The BLUSHED-AHF trial demonstrated feasibility for LUS-CS-guided therapy in acute heart failure (AHF). We investigated two questions: 1) does change (∆) in LUS-CS from emergency department (ED) to hospital-discharge predict patient outcomes, and 2) is the relationship between in-hospital decongestion and adverse events moderated by baseline risk-factors at admission? METHODS: We performed a secondary analysis of 933 observations/128 patients from 5 hospitals in the BLUSHED-AHF trial receiving daily LUS. ∆LUS-CS from ED arrival to inpatient discharge (scale -160 to +160, where negative = improving congestion) was compared to a primary outcome of 30-day death/AHF-rehospitalization. Cox regression was used to adjust for mortality risk at admission [Get-With-The-Guidelines HF risk score (GWTG-RS)] and the discharge LUS-CS. An interaction between ∆LUS-CS and GWTG-RS was included, under the hypothesis that the association between decongestion intensity (by ∆LUS-CS) and adverse outcomes would be stronger in admitted patients with low-mortality risk but high baseline congestion. RESULTS: Median age was 65 years, GWTG-RS 36, left ventricular ejection fraction 36 %, and ∆LUS-CS -20. In the multivariable analysis ∆LUS-CS was associated with event-free survival (HR = 0.61; 95 % CI: 0.38-0.97), while discharge LUS-CS (HR = 1.00; 95%CI: 0.54-1.84) did not add incremental prognostic value to ∆LUS-CS alone. As GWTG-RS rose, benefits of LUS-CS reduction attenuated (interaction p < 0.05). ∆LUS-CS and event-free survival were most strongly correlated in patients without tachycardia, tachypnea, hypotension, hyponatremia, uremia, advanced age, or history of myocardial infarction at ED/baseline, and those with low daily loop diuretic requirements. CONCLUSIONS: Reduction in ∆LUS-CS during AHF treatment was most associated with improved readmission-free survival in heavily congested patients with otherwise reassuring features at admission. ∆LUS-CS may be most useful as a measure to ensure adequate decongestion prior to discharge, to prevent early readmission, rather than modify survival.

Comparison of Trauma and Burn Evaluations in a Pediatric Emergency Department During Pre, Early and Late COVID-19 Pandemic.

BACKGROUND: Pediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown. OBJECTIVES: To compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic. METHODS: We performed a retrospective study of trauma consults for an injury/burn in children ≤16 years between January 1, 2019 and December 31, 2021. Study period was categorized into pre (January 1, 2019-February 28, 2020), early (March 1, 2020-December 31, 2020), and late (January 1, 2021-December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted. RESULTS: A total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6-2.82 and RR: 2.24, 95% CI: 1.39-3.63, respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09-1.86 and RR: 2.44, 95% CI: 1.55-3.83, respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods. CONCLUSIONS: Trauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.