External evaluation of Brain Injury Guideline (BIG) low risk criteria for traumatic brain injury.

BACKGROUND: Fewer than 20 % of traumatic brain injury (TBI) cases with traumatic intracranial hemorrhage (ICH) result in clinical deterioration. The Brain Injury Guideline (BIG) criteria were published in 2014 and categorize patients with TBI into three risk groups (BIG 1, 2, and 3) based on CT scan findings, neurological examination, anti-coagulant/platelet medications, and intoxication. Early data is promising, suggesting no instances of neurosurgical intervention or death in the low-risk BIG1 category within 30 days. We sought to externally validate the BIG criteria and identify patients with TBI at low risk of clinical deterioration. We hypothesized that patients meeting the BIG1 low risk criteria have less than a 1 % risk of death or neurosurgical intervention. METHODS: We performed a retrospective cohort study of a level 1 trauma center's trauma registry records from 2011 to 2022 to identify patients with head trauma. We abstracted demographics, injury characteristics, clinical course, CT imaging results, and outcomes, and we categorized patients according to the BIG criteria. The Clopper-Pearson Exact method was used to estimate outcome frequency with confidence intervals. The primary outcome was death or neurosurgical intervention within 30 days. Secondary outcomes included progression on repeat head CT (RHCT), ICU admission with neurocritical care intervention, and TBI-related hospital readmission within 30 days. RESULTS: A total of 1714 patients with TBI with ICH were identified from the trauma registry. 325 patients were excluded due to missing data, pregnancy, incarceration, polytrauma, or GCS < 13, leaving 1389 for analysis. 193 patients (13.9 %) were classified as BIG1. No patients classified as BIG1 experienced the primary outcome measures of death or neurosurgical intervention (95 % confidence interval [CI]: 0 %-1.9 %). The number of patients who experienced the secondary outcome measures of progression on RHCT, ICU admission with neurocritical care intervention, or TBI-related hospital readmission within 30 days were 9 (4.7 %, 95 % CI: 2.2 %-8.7 %), 1 (0.5 %, 95 % CI: 0 %-2.9 %), and 4 (2.1 %, 95 % CI: 0.6 %-5.2 %), respectively. CONCLUSION: BIG1 criteria identified a low-risk subset of patients with TBI with ICH. However, an upper 95 % CI of 1.9 % does not exclude the risk of neurologic deterioration being <1 %. Validation of these criteria in larger cohorts is warranted.

Program director longevity in emergency medicine residencies: A 40-year analysis.

Objective: We sought to assess trends in emergency medicine residency program director (PD) length of service over the past 40 years and evaluate relationships between duration of service and important factors such as PD start year, geographic region, and year of program initial accreditation. Methods: We retrospectively analyzed program data from the American Medical Association Graduate Medical Education Directory and Emergency Medicine Residents' Association Match database. We calculated descriptive statistics and used linear regression to assess the impact of PD start year, region, and year of program initial accreditation on PD duration of service. Results: We gathered data on 783 unique PDs between 1983 and 2023. The overall mean ± SD PD duration of service was 6.19 ± 4.72 years (range 1-29 years). The mean duration of service by decade of start date was 6.49 years in the 1980s, 7.39 years in the 1990s, 5.92 years in the 2000s, 4.08 years in the 2010s, and 2 years in the 2020s. Both PD start year (p = 0.002) and program initial accreditation year (p = 0.001) significantly predicted duration of PD service. Region did not significantly predict duration of PD service (p = 0.225). Conclusions: Duration of service as a PD is decreasing in recent decades. Both PD start year and year of initial program accreditation significantly predict duration of service as PD. Future research must be done to better understand this phenomenon and uncover strategies to promote PD longevity.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Precision of time devices used by prehospital providers.

BACKGROUND: As many medical, medicolegal, and research interests have become more time-dependent, increased weight should be placed on the precision of time documentation and timing devices. Studies have previously documented poor synchronization of timing devices in the medical setting. Objective. To determine whether any advancement has been made in prehospital time accuracy and to determine the timing devices used by today's emergency medical services (EMS) providers. METHODS: Times recorded from the timing devices available for use during calls by local EMS providers, including watches, cellular phones, cardiac monitors/ defibrillators, ambulance clocks, and public safety answering points, were compared with atomic time to determine accuracy. Additionally, the preferred provider timing device, and accuracy of said device, was obtained. RESULTS: A total of 138 available timing devices were observed, with an accuracy of only 36.9%; cell phones had the best accuracy (67.7%). For the 53 providers surveyed, watches (64.2%) were found to be the most used timing device, followed by cell phones (24.5%) and ambulance clocks (11.3%). Only 18 (34.0%) of these preferred devices were accurate when compared with atomic time. CONCLUSIONS: There is no precision or consistency in the timing devices used by EMS personnel. However, methods are available, such as those that support the cellular phone industry, that would help with consistent and precise timekeeping. Utilization of modern technologies could increase precision in patient documentation and decrease medical, medicolegal, and research issues relating to time documentation.