Comparison of the Effectiveness of Shock Index, Modified Shock Index, and Age Shock Index in COPD Exacerbations.

OBJECTIVE: To evaluate the effectiveness and practicality of shock index (SI), modified shock index (MSI), and age-shock index (Age-SI) in predicting the prognosis, mortality, ICU and service admission, and the need for intermittent mandatory ventilation (IMV) and nasal intermittent mandatory ventilation) (NIMV in the ED patients with chronic obstructive pulmonary disease (COPD) exacerbation. STUDY DESIGN: Retrospective study. PLACE AND DURATION OF STUDY: Balikesir University Faculty of Medicine, Emergency Service, Balikesir, Turkey, from January 2019 to May 2020. METHODOLOGY: Adult patients, who were admitted to the Emergency Department with diagnosis of COPD exacerbation, were included. Patients with missing data were excluded. SI, MSI, and age-SI values were calculated by using the vital signs. ROC curve analysis was used to evaluate the diagnostic performances of SI, MSI, and age-SI. RESULTS: The study consisted of 201 patients, 152 (75.6%) were males. Six (3%) patients died, 26 (12%) were admitted to ICU, 112 (55.7%) were admitted to the service, 11 (5.5%) needed IMV, and 48 (23.9%) needed NIMV in ED. SI was superior to the MSI and age-SI in predicting mortality, and AUC values of 0.802, 0.727, and 0.704, respectively. SI was also superior to the MSI and age-SI in predicting hospital admissions (SI AUC=0.591, p=0.029; MSI AUC=0.572, p=0.059; and age-SI AUC=0.580, p=0.089). CONCLUSION: Respectively none of the three indices was independently sufficient in predicting IMV, NIMV, and the need for ICU. SI is a valuable parameter in discriminating the COPD exacerbation. It is superior to the MSI and age-SI in predicting mortality and hospital admissions. It will be useful to evaluate SI for the severity classification, follow-up, and management of the patients with COPD. KEY WORDS: Age shock index, Chronic obstructive pulmonary disease, Modified shock index, mortality, Shock index.

Performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for predicting 30-day adverse outcomes in patients with suspected infection.

BACKGROUND: The use of the quick sequential organ failure assessment score (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to identify patients at high risk for adverse outcomes in the emergency department (ED) remains controversial due to their low predictive performance and lack of supporting evidence. This study aimed to determine the predictive performance of qSOFA, SIRS, and the qSOFA + SIRS combinations for adverse outcomes. METHODS: All adult patients admitted to the ED with suspected infection were prospectively included. qSOFA scores ≥ 2, SIRS score ≥ 2 were defined as risk-positive for adverse outcome. Furthermore, combination­1, which was defined as either qSOFA or SIRS positivity, and combination­2, which was defined as both qSOFA and SIRS positivity, were also considered as risk-positive for adverse outcome. The predictive performance of qSOFA, SIRS, combination­1, and combination­2 for a composite adverse outcome within 30 days, including mortality, intensive care unit (ICU) admission, and non-ICU hospitalization, were determined. RESULTS: A total of 350 patients were included in the analysis. The composite outcome occurred in 211 (60.3%) patients within 30 days: mortality in 84 (24%), ICU admission in 78 (22.3%), and non-ICU hospitalization in 154 (44%). The sensitivity and specificity, respectively, were determined in predicting composite outcome as 0.34 and 0.93 for qSOFA, 0.81 and 0.31 for SIRS, 0.84 and 0.28 for combination­1, and 0.31 and 0.96 for combination­2. CONCLUSION: The study results suggest that qSOFA and combination­2 could be a useful tool for confirming patients at high risk for adverse outcomes. Although SIRS and combination­1 could be helpful for excluding high-risk patients, the requirement of white blood cell counts limits their utilization for screening.

A randomized controlled trial of the effects of local tranexamic acid on mortality, rebleeding, and recurrent endoscopy need in patients with upper gastrointestinal hemorrhage.

OBJECTIVE: Tranexamic acid (TXA) is an antifibrinolytic agent used to control bleeding in different circumstances. We conducted a randomized controlled trial to assess the efficacy and safety of locally administered TXA in upper gastrointestinal hemorrhage. METHODS: This single-center, double-blind, randomized controlled trial was performed in a tertiary emergency department (ED) in patients presenting with upper gastrointestinal bleeding symptoms between 2016 and 2018. The patients received either 2000 mg of 5% TXA in 100 mL of isotonic saline solution or 100 mL isotonic saline (control group) via the nasogastric route. As a composite outcome, recurrent endoscopy need, rebleeding, surgery need, recurrent admission to the ED, and mortality parameters were evaluated at the end of a one-month period. RESULTS: During the study period, 78 patients were randomized into the TXA group, and 79 patients were randomized into the isotonic saline group. The majority of the bleedings (61%) were in Forrest class 3, and the most frequent cause was peptic ulcer disease. The composite outcome occurred in 25 of the TXA patients (32.1%) and 23 of the isotonic saline patients (29.1%); no statistically significant difference was found between the groups (P = 0.690). In addition, no statistically significant differences were observed between the TXA and control groups regarding mortality (10.3 vs 12.7%; P = 0.637), recurrent ED admission (17.9 vs 12.7%; P = 0.357), or thromboembolic complications (3.8 vs 1.3%; P = 0.367). CONCLUSION: Locally administered TXA confers no additional benefit over standard care in patients with upper gastrointestinal hemorrhage.

Role of Electrocardiographic Manifestations in Admission Decision in Patients with Chronic Obstructive Pulmonary Disease Exacerbation.

OBJECTIVE: To determine the ECG manifestations of COPD exacerbations and their roles in the decision making process in admission. STUDY DESIGN: A descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Emergency Department (ED) of Kocaeli University, Turkey, from November 2016 to December 2017. METHODOLOGY: All COPD patients who presented with exacerbation symptoms and agreed to participate in the study were enrolled, and the exacerbation characteristics were recorded in the standardised charts. Patients were excluded if they refused to participate in the study, if they presented repetitively to the ED with the same presentation, and if the ECG strip at the presentation could not be obtained. A binary logistic regression model was constructed to assess the factors predicting hospital admission, including the ECG features. RESULTS: A total of 146 patients were included in the final analysis. Upon presentation, 122 patients (83.6%) exhibited sinus rhythm, 21 exhibited atrial fibrillation (14.4%), and 3 of them were multifocal atrial tachycardia and junctional rhythm. Thirty-four admitted patients (41.0%) and 22 of the discharged patients (34.9%) exhibited ST and T wave changes in their ECGs (p=0.457). No statistically significant differences were found regarding the rhythms, axes, P wave characteristics, PR interval durations, QRS interval durations, corrected QT(QTc) durations, and bundle branch block occurrences between the admitted and discharged patients. Although the QTc dispersion was more prominent in the admitted group in the univariate analysis (p=0.035), the multivariate analysis revealed that only hypoxemia, older age, increased dyspnea scores, and sputum purulence were independent predictors of hospital admission. CONCLUSION: None of the ECG findings were determined to be successful in predicting the admission needs in COPD exacerbations.

Intravenous metoclopramide in the treatment of acute migraines: A randomized, placebo-controlled trial.

OBJECTIVES: The present study aimed to evaluate the efficacy and safety of intravenous metoclopramide for acute migraine treatment. MATERIALS AND METHODS: A double-blind, randomized, parallel-group, placebo-controlled trial was carried out in an academic emergency department. After the patients were assessed for eligibility via the International Headache Society criteria for migraines, they were randomized into 10 mg intravenous metoclopramide and normal saline groups. The headache intensity was evaluated using an 11-point numeric rating scale (NRS) score. The primary outcome measure was determined as the median between-group change in the score at the 30th minute. The secondary outcome measures were rescue medication needs, adverse events, and emergency department (ED) revisits after discharge. RESULTS: A total of 148 patients were randomized into two equal groups with similar baseline characteristics, including the baseline NRS scores (8 points). The median reduction in the NRS scores at the 30th minute was 4 [interquartile range (IQR): 2-6)] in the metoclopramide group and 3 (IQR: 1-4) in the normal saline group [median difference: -1.0, 95% confidence interval (CI): -2.1 to 0.1]. No serious adverse events were observed, and the rescue medication needs were similar in both groups. CONCLUSION: No difference was found between intravenous metoclopramide and placebo regarding efficacy and safety in patients with acute migraines.

The value of lactate clearance in admission decisions of patients with acute exacerbation of COPD.

BACKGROUND: Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations. METHODS: This single-center, cross-sectional study was conducted in a tertiary emergency department (ED) on patients who presented with acute exacerbation of COPD. Discharge or admission decisions were specified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and the clinician's decision. In the study, lactate clearance was defined as the percent decrease in lactate from the time of presentation to the ED to the sixth hour. RESULTS: A total of 495 patients were evaluated and 397 patients were excluded. Among included patients, 53 (54.1%) were admitted to the hospital and 45 (45.9%) were discharged. The median lactate clearance was found to be -11.8% (95% CI: -50.0 to 34.5) in the admitted group and 14.7% (95% CI: -11.3 to 42.3) in the discharged group. Between the two groups, the median difference of lactate clearance was found to be 26.5% (95% CI: 0.6 to 52.4). Multivariate logistic regression analysis revealed that the delta lactate value can determine the hospitalization need of patients (OR: 0.91, 95% CI: 0.85 to 0.97). CONCLUSION: Lactate clearance can be evaluated as a useful marker in patients with COPD exacerbations. This study suggests that lactate monitoring in the ED has clinical benefits in addition to GOLD guidelines when deciding whether to discharge or hospitalize a patient.