Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department.

INTRODUCTION: While numerous studies have found emergency department (ED) lactate levels to be associated with increased in-hospital mortality, little information is available on the role age plays in this association. This study investigates whether age is a necessary variable to consider when using lactate levels as a marker of prognosis and a guide for management decisions in the ED. METHODS: This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A total of 13,506 lactate levels were obtained over a 4.5-year period. All adult patients who had a lactate level obtained by the treating provider in the ED were screened for inclusion. The main outcome measure was in-hospital mortality using age-adjusted cohorts and expanded lactate thresholds with secondary outcomes comparing mortality based on the primary clinical impression. RESULTS: Of the 8796 patients in this analysis, there were 474 (5.4%) deaths. Mortality rates increased with both increasing lactate levels and increasing age. For all ages, mortality rates increased from 2.8% in the less than 2.0 millimoles per liter (mmol/L) lactate level, to 5.6% in the 2.0-2.9 mmol/L lactate level, to 8.0% in the 3.0-3.9 mmol/L lactate level, to 13.9% in the 4.0-4.9 mmol/L lactate level, to 13.7% in the 5.0-5.9 mmol/L lactate level, and to 39.1% in the 6.0 mmol/L or greater lactate level (p <0.0001). Survivors, regardless of age, had a mean lactate level <2.0 whereas non-survivors had mean lactate levels of 6.5, 4.5, and 3.7 mmol/L for age cohorts 18-39, 40-64, and ≥ 65 years, respectively. CONCLUSION: Our findings suggest that although lactate levels can be used as a prognostic tool to risk stratify ED patients, the traditional lactate level thresholds may need to be adjusted to account for varying risk based on age and clinical impressions.

The modified rapid emergency medicine score: A novel trauma triage tool to predict in-hospital mortality.

BACKGROUND: Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine (REMS) Score for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the "Mechanism, Glasgow Coma Scale, Age and Arterial Pressure" (MGAP) score, and the Shock Index (SI) score. METHODS: The two-part study design involved both a modification step and a validation step. The first step incorporated a retrospective analysis of a local trauma database (3680 patients) where three components of REMS were modified to more accurately represent the trauma population. Using clinical judgment and goodness-of-fit tests, systolic blood pressure was substituted for mean arterial pressure, the weighting of age was reduced, and the weighting of Glasgow Coma Scale was increased. The second part comprised validating the new modified REMS (mREMS) score retrospectively on a U.S. National Trauma Databank (NTDB) that included 429,711 patients admitted with trauma in 2012. The discriminate power of mREMS was compared to other trauma scores using the area under the receiver operating characteristic (AUC) curve. RESULTS: Overall the mREMS score with an AUC of 0.967 (95% CI: 0.963-0.971) was demonstrated to be higher than RTS (AUC 0.959 [95% CI: 0.955-0.964]), ISS (AUC 0.780 [95% CI 0.770-0.791]), MGAP (AUC 0.964 [95% CI: 0.959-0.968]), and SI (AUC 0.670 [95% CI: 0.650-0.690]) in predicting in-hospital mortality on the NTDB. CONCLUSION: In the trauma population, mREMS is an accurate predictor of in-hospital mortality, outperforming other used scores. Simple and objective, mREMS may hold value in the pre-hospital and emergency department setting in order to guide trauma team responses.

Health Supply Utilization at a Boy Scout Summer Camp: An Evaluation for Improvement and Preparedness.

OBJECTIVE: To describe the health conditions treated by a health services center at a Boy Scout summer camp and make recommendations for appropriate resources and supplies. METHODS: We conducted a retrospective review of health center utilization at a Boy Scout camp in central Missouri during the summers of 2012 and 2013. Health logbook data were compiled and analyzed using descriptive and comparative statistics. RESULTS: During the study period 19,771 camp participants made 1586 visits to the health care center. The overall incidence rate of health center visits was 6.20 visits per 1000 camp days. Two-thirds of visits were for illness and the remainder for injury. Over 90% of patients were returned to camp, 7.3% were transferred to another health facility, and 1.6% were advised to leave camp and return home. The most common treatments were rehydration (17.8 %) and administration of analgesics (13.4%) and topical creams (12.3%). CONCLUSIONS: Summer camps need to be prepared for a wide range of conditions and injuries in youth campers, leaders, and staff members. Over 90% of presenting complaints were managed on site, and the majority of conditions were easily treatable minor injuries and illnesses. We provide recommendations for appropriate medical supplies and suggest opportunities for improvement to aid health centers in planning and treatment.