Healthcare disparities in trauma: why they exist and what we can do.

PURPOSE OF REVIEW: This review will explore the underlying causes of healthcare disparities among trauma patients and offer considerations for reducing inequities to improve trauma care. RECENT FINDINGS: Newly recognized racial disparities exist with respect to triaging trauma patients and in acute pain management. Social Determinants of Health offers a model to understand disparity in trauma care. SUMMARY: Race, ethnicity, socioeconomic status, and access to healthcare drive outcome disparity among trauma patients. These disparities include reduced healthcare services, inadequate pain management, reduced postdischarge care, and increased mortality. Increasing workforce diversity may mitigate implicit bias and improve cultural competency. Social determinants of health impact the disparities in trauma care and offer a framework to address care through creative solutions.

Clozapine-Associated Aspiration During Electroconvulsive Therapy.

Clozapine-induced gastric hypomotility (CIGH) is an underreported, underrecognized effect from high-dose clozapine. In this report, we present a patient with treatment refractory schizophrenia receiving high-dose clozapine who aspirated during general anesthesia for electroconvulsive therapy. To our knowledge, this is the first report of aspiration under general anesthesia as a result of CIGH and highlights the potential dangers high-dose clozapine can pose on patients undergoing electroconvulsive therapy with unrecognized CIGH.

Emergency Department-initiated High-flow Nasal Cannula for COVID-19 Respiratory Distress.

INTRODUCTION: Patients with coronavirus disease 2019 (COVID-19) can develop rapidly progressive respiratory failure. Ventilation strategies during the COVID-19 pandemic seek to minimize patient mortality. In this study we examine associations between the availability of emergency department (ED)-initiated high-flow nasal cannula (HFNC) for patients presenting with COVID-19 respiratory distress and outcomes, including rates of endotracheal intubation (ETT), mortality, and hospital length of stay. METHODS: We performed a retrospective, non-concurrent cohort study of patients with COVID-19 respiratory distress presenting to the ED who required HFNC or ETT in the ED or within 24 hours following ED departure. Comparisons were made between patients presenting before and after the introduction of an ED-HFNC protocol. RESULTS: Use of HFNC was associated with a reduced rate of ETT in the ED (46.4% vs 26.3%, P <0.001) and decreased the cumulative proportion of patients who required ETT within 24 hours of ED departure (85.7% vs 32.6%, P <0.001) or during their entire hospitalization (89.3% vs 48.4%, P <0.001). Using HFNC was also associated with a trend toward increased survival to hospital discharge; however, this was not statistically significant (50.0% vs 68.4%, P = 0.115). There was no impact on intensive care unit or hospital length of stay. Demographics, comorbidities, and illness severity were similar in both cohorts. CONCLUSIONS: The institution of an ED-HFNC protocol for patients with COVID-19 respiratory distress was associated with reductions in the rate of ETT. Early initiation of HFNC is a promising strategy for avoiding ETT and improving outcomes in patients with COVID-19.

Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations.

Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.

Navigating Goals of Care While Confronting an Urgent, Difficult Intubation: A Case Report.

Urgent airway management is challenging because time constraints limit thorough evaluation and planning before endotracheal intubation. In this report, we describe a case in which an airway history review revealed extraordinarily complex airway anatomy that led to a decision not to attempt intubation in a man with end-stage chronic obstructive pulmonary disease. We emphasize the utility of reviewing history and imaging before attempted urgent intubation. We discuss the importance of a multidisciplinary approach that includes the patient, their family, and consultants when high-risk intubation is contemplated. The ethical role of the anesthesiologist is also discussed.