Predictive Factors for First-Pass Intubation Failure in Trauma Patients.

Objective: The primary objective of this study was to elucidate risk factors for multiple intubation attempts (MIA) in trauma patients requiring emergent tracheal intubation (ETI). Risk factors for mortality, intensive care unit (ICU) admission, and prolonged ventilation were assessed as secondary outcomes. The association between multiple intubation attempts and adverse outcomes has been well described in the literature. Though previous studies have identified anatomical risk factors for difficult airways, no study to date has investigated predictors for MIA in a trauma setting. Methods: The retrospective study involved 174 adult patients who required ETI and who presented to a Level 1 Trauma Center's emergency department between January 2019 and December 2022. Comorbidities, demographic information, triage vitals, intubation characteristics, and patient outcomes were identified to ascertain predictive risk factors for MIA. Variables were assessed for statistical significance on unadjusted analysis. Significant variables were entered into multivariate logistic regression models to test for adjusted associations, with p≤.0.05 as statistically significant, and presented as adjusted odds ratios with 95% confidence intervals. Results: Twenty-six (14.9%) of the 174 patients required multiple intubation attempts. There were no significant associations between MIA and patient gender, age, BMI, race, injury mechanism, or specific body region injuries. On univariate analysis, the MIA group had a statistically significant elevation in mean systolic blood pressure (151.71 ± 45.96 vs 133.55 ± 32.11, p = 0.019) and heart rate (106.30 ± 34.92 vs 93.35 ± 24.82, p < 0.032) compared to subjects with first-pass success. Elevation in systolic blood pressure (SBP) (151.71 ± 45.96 vs 133.55 ± 32.11, aOR 1.03 (1.01-1.06), p < 0.015) was an independent predictor of multiple intubation attempts. Conclusion: Elevation in SBP was a significant predictor of multiple intubation attempts. Critical appraisal of patients requiring ETI with elevated SBP may mitigate risk in trauma settings.

Multinomial Estimations of Predictive Risk Factors for Traumatic Brain Injuries.

Introduction Traumatic brain injuries (TBIs) affect millions of patients each year, with more than 220,000 hospitalizations in 2019 and 64,000 deaths in 2020 alone. TBIs span a plethora of injuries including cerebral contusions and lacerations, axonal injuries, optic pathway disruptions, and skull fractures. Previous research has established that characteristics such as sex, mechanism of injury (MOI), and blood-thinning agents have some causal connections to a variety of cranial traumas. Methods This paper sought to analyze aggravating risk factors for various TBIs in the New York City borough of Staten Island. Data on eight predictive risk variables were collected at a level 1 trauma center from January 1, 2022, to December 31, 2022: MOI, seizure history, anticoagulant/antiplatelet therapy, alcoholism, age, biological sex, tested alcohol level, and body mass index (BMI). A multinomial logistic regression was estimated to generate risk ratios (RRs), and chi-squared tests were carried out to determine univariate associations. Results It was found that blood thinner use and sex were both significant predictors of various types of TBIs. Additionally, those not tested for alcohol, including pediatric patients, were less likely to suffer most forms of TBI, while BMI had a negligible relationship with any TBI class. The use of blood-thinning agents put patients at an increased risk of concussions (relative risk ratio [RRR]: 1.82; 95% confidence interval [CI]: 1.10-3.02) and undiagnosed intracranial injuries (RRR: 1.90; 95% CI: 1.08-3.34). Men were at higher risk of multiple cranial injuries than women (RRR: 3.62; 95% CI: 1.38-9.48), as well as physical traumas such as brain lacerations and hemorrhages (RRR: 2.81, 95% CI: 1.28-6.18). BMI was weakly correlated with undiagnosed cranial injuries (RRR: 1.04; 95% CI: 1.00-1.08) and slightly uncorrelated with physical traumas (RRR: 0.94; 95% CI: 0.88-1.00). Those not tested for alcohol were at far less risk of multiple TBIs (RRR: 0.08; 95% CI: 0.01-0.66), concussions (RRR: 0.27; 95% CI: 0.11-0.71), and physical brain traumas (RRR: 0.33; 95% CI: 0.13-0.84). No parameter exhibited any statistical significance with skull fractures. Conclusion Particular risk factors for TBIs include biological sex and blood thinner use. Injury prevention efforts should be based on the category of TBI, with a particular focus on blood thinner users becoming concussive post-trauma. Attention should also be paid to men who engage in risky behavior such as binge drinking and crime sustaining more than one brain trauma or isolated brain bleeds. Therefore, improved hospital outreach for fall precautions in nursing homes and targeted interventions for at-risk men are vital for future projects.

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

"Be quick": a systems response to overcrowding in the pediatric emergency department.

OBJECTIVE: The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED. METHODS: System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007). RESULTS: The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007. CONCLUSIONS: In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.