The games: what can the sports medicine community learn from raves?

Electronic dance music festivals, also known as raves, are increasing in popularity. Despite the occasional tragedy in the lay press regarding medical incidents at raves, such events are relatively safe when compared to other mass gatherings. While the medical usage rates are lower than rock concerts and marathons, there are many similarities to both types of events with regard to the types of injuries and medical complaints. This article may assist in planning medical support for raves in the future.

Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.

PURPOSE: The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock. MATERIALS AND METHODS: This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed. RESULTS: Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (-0.46 to 1.80), and 4.00 (-8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01). CONCLUSIONS: The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.

Cardiac index measurements by transcutaneous Doppler ultrasound and transthoracic echocardiography in adult and pediatric emergency patients.

INTRODUCTION: Non-invasive hemodynamic monitoring may facilitate resuscitation in critically ill patients. Validation studies examining a transcutaneous Doppler ultrasound technology, USCOM-1A, using pulmonary artery catheter as the reference standard showed varying results. In this study, we compared non-invasive cardiac index (CI) measurements by USCOM-1A with transthoracic echocardiography (TTE). METHODS: This study was a prospective, observational cohort study at a university tertiary-care emergency department, enrolling a convenience sample of adult and pediatric patients. Paired measures of CI, stroke volume index (SVI), aortic outflow tract diameter (OTD), velocity time integral (VTI) were obtained using USCOM-1A and TTE. Pearson's correlation and Bland-Altman analyses were performed. RESULTS: One-hundred and sixteen subjects were enrolled, with obtainable USCOM-1A CI measurements for 99 subjects (55 adults age 50 +/- 20 years and 44 children age 11 +/- 4 years) in the final analysis. Cardiac, gastrointestinal and infectious illnesses were the most common presenting diagnostic categories. The reference standard TTE measurements of CI, SVI, OTD, and VTI in all subjects were 3.08 +/- 1.18 L/min/m(2), 37.10 +/- 10.91 mL/m(2), 1.92 +/- 0.36 cm, and 20.36 +/- 4.53 cm, respectively. Intra-operator reliability of USCOM-1A CI measurements showed a correlation coefficient of r = 0.79, with 11 +/- 22% difference between repeated measures. The bias and limits of agreement of USCOM-1A compared to TTE CI were 0.58 (-1.48 to 2.63) L/min/m(2). The percent difference in CI measurements with USCOM-1A was 31 +/- 28% relative to TTE measurements. CONCLUSIONS: The USCOM-1A hemodynamic monitoring technology showed poor correlation and agreement to standard transthoracic echocardiography measures of cardiac function. The utility of USCOM-1A in the management of critically ill patients remains to be determined.

Standardization of severe sepsis management: a survey of methodologies in academic and community settings.

BACKGROUND: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. OBJECTIVE: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. METHODS: In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. RESULTS: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6-12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. CONCLUSIONS: Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.

Motocross medicine.

Motocross is an increasingly popular but high-risk sport. This article reviews the history of motocross, the relevant medical literature, the unique medical issues, safety equipment, and the expert recommended approach to providing support for such events. Assessment of an injured rider on or near a track requires a provider to first ensure scene safety, then assess for airway, cervical spine, and head injuries before proceeding. Although extremity injuries are the most common injury, motocross riders frequently sustain significant spine and head trauma as well. Caregivers need to have a complete understanding of the protective gear used in motocross. They also need to be able to understand what injuries can be treated at the scene and which need transport to a hospital for more definitive care.

Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.

Physiologic scoring systems are often used to prognosticate mortality in critically ill patients. This study examined the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality in Emergency Department Sepsis (MEDS), and Mortality Probability Models (MPM) II0 in predicting in-hospital mortality of patients in the emergency department meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The discrimination and calibration characteristics of APACHE II, SAPS II, MEDS, and MPM II0 were evaluated. Data are presented as median and quartiles (25th, 75th). Two-hundred forty-six patients aged 68 (52, 81) years were analyzed from a prospectively maintained sepsis registry, with 76.0% of patients in septic shock, 45.5% blood culture positive, and 35.0% in-hospital mortality. Acute Physiology and Chronic Health Evaluation II, SAPS II, and MEDS scores were 29 (21, 37), 54 (40, 70), and 13 (11, 16), with predicted mortalities of 64% (40%, 85%), 58% (25%, 84%), and 16% (9%, 39%), respectively. Mortality Probability Models II0 showed a predicted mortality of 60% (27%, 80%). The area under the receiver operating characteristic curves was 0.73 for APACHE II, 0.71 for SAPS II, 0.60 for MEDS, and 0.72 for MPM II0. The standardized mortality ratios were 0.59, 0.63, 1.68, and 0.64, respectively. Thus, APACHE II, SAPS II, MEDS, and MPM II0 have variable abilities to discriminate early and estimate in-hospital mortality of patients presenting to the emergency department requiring the severe sepsis resuscitation bundle. Adoption of these prognostication tools in this setting may influence therapy and resource use for these patients.

The utility of a quality improvement bundle in bridging the gap between research and standard care in the management of severe sepsis and septic shock in the emergency department.

The research in the management of severe sepsis and septic shock has resulted in a number of therapeutic strategies with significant survival benefits. These results also emphasize the primary importance of early hemodynamic resuscitation, or early goal-directed therapy (EGDT), and place the emergency physician in the center of the multidisciplinary team caring for patients with this disease. However, in a busy emergency department, the translation of research into clinical practice is far from ideal. While the benefits are significant, the successful implementation of EGDT is filled with challenges and obstacles. In this article, we will discuss the steps taken at our institution to create, implement, measure, and improve on a six-hour severe sepsis and septic shock treatment bundle incorporating EGDT in the emergency department setting, resulting in significant mortality benefit.

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality.

OBJECTIVE: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. DESIGN: Two-year prospective observational cohort. SETTING: Academic tertiary care facility. PATIENTS: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. INTERVENTIONS: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. MEASUREMENTS AND MAIN RESULTS: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). CONCLUSIONS: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.

Interrater reliability of cardiac output measurements by transcutaneous Doppler ultrasound: implications for noninvasive hemodynamic monitoring in the ED.

INTRODUCTION: Hemodynamic monitoring is an important aspect of caring for the critically ill patients boarding in the emergency department (ED). The purpose of this study is to investigate the interrater agreement of noninvasive cardiac output measurements using transcutaneous Doppler ultrasound technique. METHODS: This is a prospective observational cohort study performed in a 32-bed adult ED of an academic tertiary center with approximately 65000 annual patient visits. Patients were enrolled after verbal consent over a 7-month period. The raters were ED personnel involved in patient care. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained from a transcutaneous Doppler ultrasound cardiac output monitor. RESULTS: A convenience sample of 107 (50 women and 57 men) patients with a median age of 49 (32, 62) years was enrolled. One hundred two paired measurements were performed in 91 patients in whom adequate Doppler ultrasound signals were obtainable. The raters included 35 emergency medicine attending physicians, 31 emergency medicine residents, 80 medical students, 47 nurses, and 11 emergency medical technicians. Cardiac index range was 0.6 to 5.3 L/min per square meter, and SVI range was 7.7 to 63.0 mL/m(2). The correlation of CI measurements between 2 raters was good (r(2) = 0.87; 95% confidence interval, 0.86-1.00; P < .001). Likewise, SVI measurements between 2 raters also showed acceptable correlation (r(2) = 0.84; 95% confidence interval, 0.81-0.96; P < .001). Interrater reliability was strong for CI (kappa = 0.83 with 92.2% agreement) and SVI measurements (kappa = 0.72 with 88.2% agreement). Most patients had an interrater difference below 10% in CI and SVI measurements. CONCLUSIONS: Emergency department personnel, regardless of their role in patient care, are able to obtain reliable cardiac output measurements in ED patients over a wide range of CI and SVI. Transcutaneous Doppler ultrasound technique may be an alternative to traditional invasive hemodynamic monitoring of critically ill patients presenting to the ED.

Pediatric laryngoscope blade size selection using facial landmarks.

OBJECTIVES: The study evaluates whether facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children. We tested the hypothesis that the laryngoscope blade measuring 10 mm or less distal or proximal to the angle of the mandible (when the flat portion of the blade follows the facial contour from the upper incisor teeth to the angle of the mandible) will demonstrate greater success and ease of oral tracheal intubation. METHODS: We performed an observational study that prospectively evaluated a convenience sample of children 8 years old or younger and who were undergoing direct laryngoscopy for oral endotracheal intubation in the operating room, outpatient surgery center, emergency department, or pediatric intensive care unit of a tertiary referral medical center. Ease and success of oral tracheal intubation were compared with distance measurements from the angle of the mandible to the tip of the laryngoscope blade. RESULTS: Blade lengths considered too short (blade lengths >10 mm proximal to the angle of the mandible) were more likely to be associated with more than 1 attempt at intubation. Only 57.1% (12/21; 95% confidence interval [CI], 36.5-75.5) of the intubations using the shorter blade were performed on the first attempt as compared with 89.7% (26/29; 95% CI, 73.6-96.4) of the intubations using the recommended length or 85.7% (6/7; 95% CI, 48.7-97.4) of the intubations using blades extending longer than 10 mm past the angle of the mandible. CONCLUSIONS: The distance from the upper incisor teeth to the angle of the jaw seems to be an excellent clinical landmark for laryngoscope blade length selection for pediatric intubations. When the blade (excluding the handle insertion block) is placed at the upper midline incisor teeth and the tip is located within 1 cm proximal or distal to the angle of the mandible, oral tracheal intubations are more consistently accomplished on the first attempt. Our observations suggest that facial landmarks can be used to estimate an appropriate laryngoscope blade length for oral endotracheal intubation in children.

Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department.

OBJECTIVES: To describe our experience with early goal-directed therapy (EGDT), corticosteroid administration, and recombinant human activated protein C (rhAPC) administration in patients with severe sepsis or septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or =25 in the emergency department (ED). METHODS: This was a retrospective case series of a prospectively maintained ED sepsis registry. Data are presented as median (25th, 75th percentile). The setting was an academic tertiary ED with approximately 60,000 annual patient visits. Patients with severe sepsis or septic shock and an APACHE II score > or =25 entered in an ED sepsis registry over a four-month period were included. Patients who received rhAPC in the intensive care unit were excluded. Central venous catheterization for central venous pressure and central venous oxygen saturation monitoring, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, inotropes, corticosteroids, and rhAPC were initiated by the emergency physicians and continued in the intensive care unit by intensivists. RESULTS: Twenty-four patients were enrolled. Patient characteristics were as follows: age, 79.5 (68.0, 83.5) years; APACHE II score, 31.5 (29.8, 36.0); ED length of stay, 6.5 (4.0, 10.5) hours; predicted mortality, 76.7% (71.9, 86.4); and in-hospital mortality, 45.8%. All patients received broad-spectrum antibiotics, 54.2% completed EGDT, 33.3% received corticosteroids, and 33.3% received rhAPC. Time of antibiotic administration was 1.5 (1.0, 2.0) hours, time of central venous pressure/central venous oxygen saturation monitoring was 1.0 (0.5, 2.5) hour, and time of rhAPC administration was 9.5 (6.8, 10.5) hours after patients met criteria for severe sepsis or septic shock. In-hospital mortality of patients who received rhAPC in addition to other therapies was 25.0%. CONCLUSIONS: EGDT, corticosteroid administration, and rhAPC administration are feasible in the ED setting. While these evidence-based therapies individually have been shown to improve outcomes for patients with severe sepsis or septic shock, further studies are needed to examine their combined effectiveness during the early stages of this disease.

Most lay people can correctly identify indigenous venomous snakes.

We attempted to determine how accurately members of the public can identify venomous snakes. Six different snakes indigenous to southern California were displayed in cages for 265 people to view at a street fair. These included 4 nonvenomous snakes and 2 venomous snakes. People were asked whether the snake was venomous and the name of the snake, if they knew it. Overall, people recognized whether a snake was venomous or nonvenomous 81% of the time. They were most accurate at identifying rattlesnakes as being venomous (95%) but incorrectly identified nonvenomous snakes as being venomous 25% of the time. Men were more accurate than women, and adults were more accurate than children. Subjects were less well able to identify the exact species of snakes. The results suggest that there may be no need to capture, kill, or bring a snake to the hospital for identification, at least in this geographic area.

Street bikes versus dirt bikes: a comparison of injuries among motorcyclists presenting to a regional trauma center.

BACKGROUND: This study sought to compare the spectrum of injuries and outcomes between off-road and on-road motorcyclists. METHODS: Demographic information, accident location, helmet use, anatomic injuries, physiologic data, length of stay, transfusions, operations, Injury Severity Scores, and determination of death were abstracted for a consecutive cohort of patients over a 5-year period. RESULTS: There were no significant differences between off-road motorcyclists (n = 376) and on-road motorcyclists (n = 371) in terms of helmet use, loss of consciousness, initial systolic blood pressure, initial Glasgow Coma Scale, initial Revised Trauma Score, or hand, wrist, forearm, arm, clavicle, foot, ankle, femur, pelvis, spinal, or head injuries. On-road motorcyclists were significantly more likely, however, to require transfusions (p < 0.025); sustain blunt chest, abdominal, or skin trauma; or die (p < 0.05). CONCLUSIONS: On-road motorcyclists are more likely to sustain blunt abdominal trauma, blunt chest trauma, skin trauma, and death than off-road motorcyclists.

Violence against emergency medical services personnel.

BACKGROUND: Emergency medical services (EMS) providers may be exposed to violent behavior while performing their routine duties. OBJECTIVES: To determine the prevalence of violence against EMS providers in the prehospital setting and to determine factors associated with such violence. METHODS: Consecutive medical calls for EMS agencies in a southern California metropolitan area were prospectively analyzed for one month. Following each call, prehospital personnel recorded information about any episodes of violence (verbal or physical) during the run as well as variables felt to be associated with these behaviors. RESULTS: There were 4,102 cases available for analysis. Overall, some sort of violence occurred in 8.5% (349/4,102) of patient encounters. Of this reported violence, 52.7% (184/349) was directed against prehospital care providers, while 47.3% (165/349) was directed against others. The prevalence of violence directed against prehospital care personnel was therefore 4.5% (184/4,102). Patients accounted for most (89.7%; 165/184) of this violent behavior. The type of violence varied, with 20.7% (38/184) being verbal only, 48.9% (90/184) being physical, and 30.4% (56/184) constituting both verbal and physical attacks. Male sex, patient age, and hour of the day were significantly associated with episodes of violence. Logistic regression analysis provided odds ratios (ORs) with confidence intervals (CIs) for factors that were predictive of violent behavior. These included police presence (OR 2.8; 95% CI 1.8-4.4), apparent presence of gang members (OR 2.9; 95% CI 1.6-5.3), perceived psychiatric disorder (OR 5.9; 95% CI 3.5-9.9), and perceived presence of alcohol or drug use (OR 7.0; 95% CI 4.4-11.2). CONCLUSION: Emergency medical services providers in some areas are at substantial risk for encountering violence in the prehospital setting. Certain situational factors may be used to predict the risk of encountering violence. Training, protocols, and protective gear for dealing with violent situations should be encouraged for all prehospital personnel.