The Effect of Glycemic Control on Morbidity and Mortality in Critically Ill COVID-19 Patients.

Background COVID-19 infection has caused a global pandemic affecting a group of patients with chronic conditions including diabetes with exacerbating insulin resistance and hyperglycemia. Investigators noted that pre-existing diabetes and newly diagnosed diabetes are associated with an increased risk of all-cause mortality in hospitalized patients with COVID-19 infection. Aim To evaluate the relationship between ICU patients infected with COVID-19 and mortality among those with high versus low glucose levels. Methods This is a retrospective study of critically ill adult patients infected with COVID-19 who were admitted to the ICU from April 5, 2020, to October 14, 2020. The participants were from San Bernardino County which is a diverse and underserved community. Overall, 84 patients were included in the final analysis. The average age was 59.67 (standard deviation=15.55) with 59.5% being males. Overall mortality was 44.1%. Results Around one-fifth of patients had glucose under control as measured by peak glucose level of <180 mg/dL during hospital stay. A statistically significant association was seen between tighter serum glucose control and mortality (p=0.0354). Patients with serum glucose maintained <180 mg/dL were associated with significantly lower mortality than their counterparts (22.2% vs. 50%). Conclusions This study suggests that maintaining a tighter control of the glycemic index in critically ill COVID-19 patients will improve morbidity and mortality.

Miller-Fisher Syndrome Presenting as Facial Diplegia With COVID-19 Co-Infection.

Coronavirus disease 2019 (COVID-19) has reportedly been associated with various neurological manifestations, including unilateral facial palsy and, very rarely, facial diplegia. We present a unique case of Miller-Fisher Syndrome (MFS), a variant of Guillain-Barré Syndrome (GBS) that was noted in conjunction with a COVID-19 infection. In this case, a patient presented with bilateral facial palsy, dysarthria, right-sided hemiparesis, ataxia, and the confirmation of SARS-CoV-2 infection. His computed tomography (CT) scan of the brain and serology test results did not support alternate etiologies for facial palsy. His cerebrospinal fluid (CSF) studies demonstrated albuminocytologic dissociation, which was consistent with the diagnosis of MFS and further supported by his ataxia and ophthalmoplegia. A five-day course of intravenous immunoglobulin (IVIG) therapy combined with physical, occupational, and speech therapy improved his recovery.

Succinylcholine Administration and Resultant Pulseless Ventricular Tachycardia: A Case Report of Communication Breakdown During an Emergent Intubation.

Poor communication continues to be one of the leading root causes of sentinel events in the United States annually. This case report documents a miscommunication that occurred during the management of a patient with Guillain-Barré syndrome (GBS) and acute respiratory failure requiring emergent intubation, which resulted in a transient hyperkalemia and subsequent cardiac arrest.

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department.

INTRODUCTION: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in gross morbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. This study analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed to have cellulitis, as well as the capability to differentiate cellulitis from NF. METHODS: This was a 10-year retrospective chart-review study that included emergency department (ED) patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from 0-13 for each patient with all pertinent laboratory values. Three categories were developed per the original LRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINEC score 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence of a C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC score was 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the "low risk" group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the "high risk" group. These patients missing CRP values were added to these respective groups. RESULTS: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) were moderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22 patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patients without CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, a total of 47 patients were further classified based on LRINEC score without a CRP value. More than half of the NF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to perform better in the diabetes population than in the non-diabetes population. CONCLUSION: The LRINEC score may not be an accurate tool for NF risk stratification and differentiation between cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive rate when determining NF risk stratification in confirmed cases of cellulitis and a high false negative rate in cases of confirmed NF.

Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma.

BACKGROUND: A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy. METHODS: This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between self-reported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy. RESULTS: Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one. CONCLUSION: Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home. LEVEL OF EVIDENCE: Level III, therapeutic/care management.

The San Bernardino, California, Terror Attack: Two Emergency Departments' Response.

On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims. In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care. MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in management of future MCIs.

With practice, keyboard shortcuts become faster than menu selection: A crossover interaction.

It is widely believed that a graphical user interface (GUI) is superior to a command line interface (CLI) for novice users, but less efficient than the CLI after practice. However, there appears to be no detailed study of the crossover interaction that this implies. The rate of learning may shed light on the reluctance of experienced users to adopt keyboard shortcuts, even though, when mastered, shortcut use would reduce task completion times. We report 2 experiments examining changes in the efficiency of and preference for keyboard input versus GUI with practice. Experiment 1 had separate groups of subjects make speeded choice responses to words on a 20-item list either by clicking on a tab in a dropdown menu (GUI version) or by entering a preassigned keystroke combination (CLI version). The predicted crossover was observed after approximately 200 responses. Experiment 2 showed that following training all but 1 subject in the CLI-trained group chose to continue using shortcuts. These results suggest that frequency of shortcut use is a function of ease of retrieval, which develops over the course of multiple repetitions of the command. We discuss possible methods for promoting shortcut learning and the practical implications of our results.

Airway registry: a performance improvement surveillance project of emergency department airway management.

The aim of this study was to determine if use of a standardized airway data collection sheet can survey airway management practices in an emergency department. Success rates and trends from the authors' facility have been benchmarked against the National Emergency Airway Registry (NEAR). This study included all patients requiring invasive airway management during a 21-month period (July 1, 2005, through March 31, 2007). An audit form was developed and implemented to collect data on intubations. During the study period, 224 patients required invasive airway control. Of all airways managed by emergency medicine residents, the intubation success rate was 99% (200/203; 95% confidence interval [CI] = 96%-100%), with 3% of those (6/203; 95% CI = 1%-6%) requiring more than 3 attempts; 3 patients (1%; 95% CI = 0%-4%) could not be intubated and required a surgical airway. Use of an airway registry based on the NEAR registry as a benchmark of rates and types of successful intubation allows comparison of airway practices.