The Use of POCUS-Obtained Optic Nerve Sheath Diameter in Intracerebral Hemorrhage.

Background: Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. ICH causes increased intracranial pressure (ICP), leading to brain herniation as the disease progresses. Neurological physical exam and monitoring of the disease progression can be challenging due to the impaired consciousness and routine clinical management in this patient population. Given the continuity of the intracranial cavity with the optic nerve subarachnoid space, an increased ICH leads to distension of the optic nerve sheath. We herein examined the correlation between the ICH volume and the optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS). Methods: Patients with ICH diagnosed with a head computed tomography (CT) scan were prospectively enrolled in this study. A portable ultrasound was used to measure the (ONSD); the volume of ICH hematoma, the Acute Physiology And Chronic Health Evaluation IV score, and the Intracerebral Hemorrhage score were collected. A Spearman rank correlation coefficient test was used to assess the relationship between continuous variables. A Wilcoxon rank sum test was used to assess differences in continuous variables between two groups. A p-value less than 0.05 was deemed as statistically significant. Results: A total of 28 subjects were enrolled. A moderate positive correlation was detected between hemorrhage volume and the average ONSD (correlation = 0.4214, p = 0.0255). A weak positive correlation was detected between average ONSD and APACHE IV (correlation = 0.2347, p = 0.2294). A weak moderate positive correlation was detected between average ONSD and ICH score (correlation = 0.1160, p = 0.5566). Conclusions: In this study we demonstrate that ONSD is moderately correlated with hematoma size. A potential application may include serial measurements of the ONSD with ultrasound. This may offer a quick, non-invasive technique that can be used in an intracerebral hemorrhage to monitor the stability or expansion of a hematoma indirectly, and potentially catch a catastrophic event like cerebral herniation.

The role of the RAPID score in surgical planning for empyema.

Background: The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema. Methods: A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores. Results: We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality. Conclusions: We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery.

Admission Hyperglycemia Is a Risk Factor for Deep Surgical-Site Infection in Orthopaedic Trauma Patients.

OBJECTIVES: To evaluate the association of admission blood glucose ≥200 mg/dL and surgical site infection in orthopaedic trauma surgery. DESIGN: Retrospective, case control study. SETTING: Academic trauma center. PATIENTS: Four hundred sixty-five nondiabetic, noncritically ill orthopaedic trauma patients with an extremity, pelvic, or acetabular fracture and requiring open reduction and internal fixation or intramedullary nailing. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Ninety-day deep surgical site infection. RESULTS: Admission blood glucose ≥200 mg/dL was significantly associated with the primary outcome (8/128, 6.3% vs. 35/337, 1.8%; P = 0.01). Multivariable logistic regression modeling demonstrated that admission blood glucose ≥200 mg/dL was a significant risk factor for deep surgical site infections [odds ratio (OR): 4.7, 95% confidence interval (CI) 1.4-15.7], after controlling for male gender (OR: 1.8, 95% CI: 1.1-3.1), prior drug or alcohol abuse (OR: 1.9, 95% CI 0.9-4.0), open fracture (OR: 6.4, 95% CI 3.7-11.0), and fracture region (upper extremity OR: reference; pelvis/hip OR: 3.9, 95% CI 1.6-9.7; femur OR: 2.0, 95% CI 0.88-4.8; tibia/ankle OR: 3.3, 95% CI 1.7-6.2; and foot OR: 2.7, 95% CI 1.2-6.3). CONCLUSIONS: Admission glucose ≥200 mg/dL was a significant independent risk factor for 90-day deep surgical site infections in orthopaedic trauma patients and may serve as an important marker for infection risk. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Head injury serum markers for assessing response to trauma: Design of the HeadSMART study.

BACKGROUND: Accurate diagnosis and risk stratification of traumatic brain injury (TBI) at time of presentation remains a clinical challenge. The Head Injury Serum Markers for Assessing Response to Trauma study (HeadSMART) aims to examine blood-based biomarkers for diagnosing and determining prognosis in TBI. METHODS: HeadSMART is a 6-month prospective cohort study comparing emergency department patients evaluated for TBI (exposure group) to (1) emergency department patients evaluated for traumatic injury without head trauma and (2) healthy persons. Study methods and characteristics of the first 300 exposure participants are discussed. RESULTS: Of the first 300 participants in the exposure arm, 70% met the American Congress of Rehabilitation Medicine criteria for TBI, with the majority (80.1%) classified as mild TBI. The majority of subjects in the exposure arm had Glasgow Coma Scale scores of 13-15 (98.0%), normal head computed tomography (81.3%) and no prior history of concussion (71.7%). CONCLUSION: With systematic phenotyping, HeadSMART will facilitate diagnosis and risk-stratification of the heterogeneous group of individuals currently diagnosed with TBI.