Prehospital Active and Passive Warming in Trauma Patients.

OBJECTIVE: Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. METHODS: In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. RESULTS: A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). CONCLUSION: For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

An Evaluation of the Use of Aggressive Fluid Resuscitation in the Early Treatment of Sepsis Patients.

Introduction Fluid resuscitation is a critical aspect of the sepsis protocol with the usual initial dose being 30 mL per kilogram. Although this dose is well accepted in patients with normal cardiac function, there is some significant variation in clinical practice concerning the optimal fluid resuscitation in septic patients with underlying congestive heart failure (CHF). Many different approaches have been tried to best treat these patients by using lesser volumes of fluid. The purpose of this retrospective study is to attempt to better define optimal fluid resuscitation in congestive heart failure patients and whether standard fluid resuscitation exacerbates CHF in these cases. Methods This was a retrospective study involving patients admitted to the Emergency Department (ED) during the time period of September of 2016 through March of 2019 with a primary diagnosis of sepsis and pre-existing CHF. Data collected from the data warehouse and patient charts included demographics, total amount of fluid received in the ED and outcome data. Evidence of fluid overload (chest X-ray [CXR] evidence, rising B-type natriuretic peptide [BNP], or use of diuretics), was evaluated with respect to in-hospital mortality, white blood cell (WBC) count and comorbidities (chronic obstructive pulmonary disease [COPD], hypertension and coronary artery disease). Results There were 422 patients included in the cohort. Of the 422, 113 (26.8%) patients showed evidence of fluid overload on CXR during hospital stay and received diuretics and therefore considered in the CHF exacerbation group. The patients that experienced CHF exacerbation were significantly older (mean ± SD, 70.9 ± 11.8 years versus 67.4 ± 15.1 years, p=0.014). Patients with exacerbation also received more fluid (median and interquartile range, 3.0, 2:5.5 L versus 2.0, 1:4.3 L, p=0.017). The receiver operating characteristic curve analysis for fluid to predict exacerbation resulted in an area under the curve of 0.59 with a 95% confidence interval (CI) of 0.52 to 0.65, p=0.012. The Youden Index was used to determine an optimal cutoff value of 2.6 L. The percentage of patients in the exacerbation group above the threshold was significantly higher (57.3%) than those without exacerbation (43.3%), p=0.019. Following multivariate analysis, age greater than 60 (odds ratio [OR]: 2.5; CI: 1.4-4.6, p=0.003) and fluid cutoff of 2.6 L (OR: 1.9; CI: 1.2-3.1, p=0.007) were both found to be independent predictors of CHF exacerbation. There was no significant difference in mortality based on the total fluid received in the ED. Conclusion The findings of this study showed that septic patients with pre-existing CHF who received more than 2.6 L of fluid in the ED were 90% more likely to develop symptoms of CHF exacerbation with no evidence of lowering mortality compared to the group that received less than 2.6 L. Our data supports the practice of limiting total fluid resuscitation in CHF to 2.6 L and reconfirms the idea that fluid resuscitation for patients with CHF needs to be individualized.

Our Experience with Transcatheter Aortic Valve Replacement Medication Outcomes from 2013 to 2016.

Background Aortic stenosis is classified as stenosis that can be caused by a congenital disability in infants and children but is more commonly produced by a degenerative process of calcification and scarring of the valve in the later decades of life. High systemic pressure and hemodynamic disturbances characteristic of this area of the cardiovascular system makes the aortic valve susceptible to plaque and cholesterol buildup over time, similarly to atherosclerosis, contributing to the pathology of aortic stenosis. Thus, this study aims to assess the short and long-term clinical outcomes of risk factor reduction, post transcatheter aortic valve replacement (post-TAVR), and results of tested medication outcomes. Methods Data were obtained from Charleston Area Medical Center, which is a tertiary care 800-bed community teaching facility and was examined using STATA 11.4 (StataCorp LLC, College Station, Texas, USA), a Cox proportional hazards model to test for clinical significance. This study examined the medications aspirin, clopidogrel, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Additional medications analyzed included statin, anticoagulant, aspirin with clopidogrel, and beta-blocker with ACE inhibitor and statin following the procedure of transcatheter aortic valve replacement (TAVR) and the overall risk of a hazard event of mortality. Results Results suggest that clopidogrel by itself had the lower rate of mortality at one year with hazards of 0.6906, a p-value of 0.221 and a 95% confidence interval of 0.3677 - 1.259; and at three years with hazards of 0.4845, a p-value of 0.027 and a 95% confidence interval of 0.2552 - 0.9201. Statins had the second-lowest rate at one year with hazards of 0.7299 and a p-value 0.215 and a 95% confidence interval of 0.4438 - 1.200; and at three years with hazard of 0.8529 and a p-value of 0.530 and a 95% confidence interval of 0.5192 - 1.401. Both of these medications had a consistent lower hazard and/or risk of death compared to other standard medication regiments. Within our center's data, clopidogrel had the best clinical outcome.  Conclusions This study showed that therapy with aspirin and clopidogrel alone did not demonstrate a significant increase in mortality versus alternative anticoagulation therapy in patients post aortic valve replacement. Clopidogrel and statin usage post-aortic valve revascularization may have a trend towards a reduction in mortality.

Comparison of Manikin Versus Porcine Trachea Models When Teaching Emergent Cricothyroidotomy Among Emergency Medicine Residents.

OBJECTIVES: Emergent cricothyroidotomy (EC) is a rarely used yet lifesaving procedure that is important for an emergency physician to master throughout his or her training. We evaluated the difference in utilization of a manikin or porcine model among emergency medicine (EM) residents when teaching EC. We also evaluated the difference in the models using two different commonly utilized and taught techniques: "scalpel-finger-bougie" (SFB) technique and the Melker technique (MT). METHODS: This was a prospective crossover design. Instructions about the procedure were provided; study participants were randomly assigned to one of two groups and performed cricothyrotomy on both manikin and porcine simulators using both the Melker and the SFB techniques. Each group was started with the technique on the second simulator opposite what they started with on the first simulator. After the procedures, study participants completed a questionnaire that used the same format for both groups. All survey questions required a 7-point Likert scale response. Confidence, difficulty, reality of the anatomy, and landmarks were compared. RESULTS: Fifteen EM residents participated in the study. Compared to the porcine-first group, the manikin-first group rated the anatomy more realistic (question 5) after their first attempt (6.29 vs. 5.87) than their second attempt (using the porcine model; 4.29 vs. 5.62; main effect for attempts [first vs. second] p = 0.027; interaction p = 0.074). Interestingly, the porcine model-first group rated the landmarks (question 6) significantly easier to find in both attempts (6.87 vs. 5.86 on the first attempt and 6.50 vs. 5.57 on the second attempt; p = 0.012). Twelve participants (80%) chose SFB as their preferred technique to use in real-life scenario. CONCLUSION: The Manikin model tends to be more realistic in cricothyrotomy simulation than the porcine model. The influence of fresh pig skin overlying the porcine model may require further research. Landmark identification during the procedure was easier on both models when participants start with the porcine model. Participants prefer the SFB over MT if faced with a real-life scenario.

Undiagnosed Diabetes in Patients Admitted to a Clinical Decision Unit from the Emergency Department: A Retrospective Review.

Objectives Diabetes is a debilitating disease that affects the way the body uses or produces insulin. Research evaluating the usefulness in screening patients admitted to a clinical decision unit (CDU) from the emergency department (ED) has been limited. Methods A retrospective chart review of patients admitted to a CDU from the ED was performed. Patients included were > 18-year-old who were observed in the CDU, had blood glucose drawn greater than eight hours after admission, and who had not been previously diagnosed with diabetes. Age, sex, and fasting glucose level were collected. The analysis was done to evaluate the percentage of patients undiagnosed and at risk for diabetes mellitus by assessing fasting blood glucose the morning after admission. Results Study revealed that 27.8% of the patients analyzed in this study had fasting blood glucose levels meeting or exceeding the diagnostic threshold of 126 mg/dL and could potentially have undiagnosed diabetes. Conclusion Screening patients admitted to a CDU from the emergency department identified that 27.8% had fasting plasma glucose levels ≥ 126 mg/dL. Consideration should be made to obtain a fasting blood glucose level in those without a previous diagnosis of diabetes who are observed overnight in a CDU.

The Intravenous Drug User with a Big Heart.

Infective endocarditis is a severe and now more frequently encountered condition given the rise of intravenous (IV) drug use. An IV drug user presented with septic shock and bacterial endocarditis. Upon imaging, a fistulous tract was discovered, communicating from the annulus of the infected mitral valve to a large left ventricular pseudoaneurysm (PA). Presence of valvular vegetation, heart failure, and PA are all independent factors of increased mortality rates. The sheer size of the PA placed this patient at a very high surgical risk, and she was deemed inoperable. She was discharged when stabilized on supportive medical therapy. However, she returned six weeks later in cardiogenic shock with multi-organ failure. Repeat imaging revealed that the PA had significantly increased in size. Despite optimal medical management, the patient's condition deteriorated, and she, unfortunately, succumbed to her illness.

Use of MitraClip for Postmyocardial Infarction Mitral Regurgitation Secondary to Papillary Muscle Dysfunction.

Papillary muscle rupture after acute myocardial infarction (AMI) is a dreadful complication and it is associated with five percent of deaths following AMI. Surgery is the recommended treatment of choice; however, it is usually deferred due to the high risk of mortality. MitraClip implantation using a transcatheter approach is an alternative option for patients with severe mitral regurgitation (MR) following AMI or those with high operative risk. We report a case of a 68-year-old male patient who developed severe MR secondary to AMI and underwent successful mitral valve repair using the MitraClip device.

Survival Analysis of Cancer Patients of Differing Payer Type in South West Virginia, Between 2000 and 2013.

Introduction The effect of insurance coverage on the health of at-risk populations is poorly understood in the Appalachian region of the United States. The goal of this study is to examine how different types of insurance coverage (Private Insurance, Medicare under 65, Medicare 65 or over, Medicaid and Self Pay) may influence cancer survival over time. This study analyzes colon, bladder, as well as combines anal, rectal, and esophageal cancers. Methods We systematically analyzed all West Virginia Cancer Registry patients between the years of 2000 and 2013 who was diagnosed with colon, bladder, anal, rectal, and esophageal cancers. Separate analysis examined colon (n = 927), bladder (n = 269), and combined anal, rectum, and esophageal cancers (n = 398). Cox proportional hazards models investigated the effect of insurance types on survival while controlling for age, sex, tobacco use, alcohol use, and cancer stage. Results Overall, tobacco use marginally significantly decreased colon cancer survival. Tobacco use had a suggestive relationship at hazards ratio at 1.150, 95% confidence interval: 0.9990-1.235, p = 0.052. The type of payer group did not alter survival. Older individuals tend to have a lower survival rate compared to those that are younger at the time of diagnosis. Also, late-stage cancer faced lower survival compared to those with early-stage cancer. Other results within stage groups corresponded to existing literature. Conclusion For the three differing cancer groupings, there was no significant survival difference for patients by insurance type. The effect of tobacco usage on colon cancer survival merits further research. The study design could be improved by considering more risk factors such as patient comorbidities that might affect patient care and survival.

Air Medical Simulation Training: A Retrospective Review of Cost and Effectiveness.

OBJECTIVE: Simulation training is an integral part of the training of medical personnel. However, there are limited data on the use of simulation in the training of helicopter emergency medical services (HEMS). METHODS: In this study, we retrospectively compared the number of orientation flights needed to be released to a full crewmember and the cost of training in an air medical flight academy before and after implementation of a high-fidelity air medical simulator. A total of 13 participants in the air medical services flight academy were analyzed. Four of these participants went through the standard academy. Nine participants went through the standard academy but had additional training using the simulator. RESULTS: There was no statistical difference in the number of orientation flights before release from training (P = .35). Also, although there was a trend that the simulator decreased the overall cost of training, there was no significant difference between the groups (P = .16). CONCLUSION: This study found that the use of a high-fidelity simulator when training HEMS personnel does not significantly reduce the number of orientation flights needed to become a full crewmember. There was a trend toward a significant reduction in the total cost of training.

Alternative Treatment Approach for Right Heart Masses.

The traditional therapeutic approach for heart masses has been surgical resection. For right-sided masses, percutaneous mechanical thrombectomy (PMT) is a viable treatment option which is being applied with increasing frequency. This newer treatment modality is less invasive, less expensive, and results in shorter hospital stays compared to cardiac surgery. We demonstrate below a case in which rheolytic PMT was utilized successfully, allowing the patient to be discharged the following day.

Clinical Features and Outcomes of Peripheral Vascular Disease Patients Receiving Red Blood Cell Transfusions.

Background Peripheral vascular disease (PVD) patients are commonly transfused with red blood cells (RBC) due to their inability to compensate for anemia and blood loss. Anemias, as well as allogeneic transfusions, have been demonstrated as independent risk factors for increased mortality and morbidity following cardiovascular procedures. The relationships between anemia, transfusion, and adverse outcomes in PVD patients remain unascertained and understudied. Methods A retrospective cohort study was conducted to determine mortality at 30-day, one-year, and three-year markers among 330 randomly selected PVD patients. The clinical features of patients receiving transfusions were examined, and the mortality rates were compared between patients who received an RBC transfusion and those who did not. Cox regression analysis was employed to identify independent variables predicting mortality. Results Transfusions were found to have increased mortality rates over non-transfused patients at 30 days (6.1% vs. 1.8%, p = 0.05), one year (21.8% vs 12.1%, p = 0.02), and three years (41.2% vs. 23.0%, p = 0.001). Using a multivariate regression model, it was determined that the transfusion itself was not a significant cause of this decrease in survival, while the propensity to transfuse was a predictor for both short (30 days, 36.73 [1.85-728.06], p = 0.04) and long-term mortality (one year (8.83 [2.62-29.77], p < 0.001; three years (7.07 [1.46-8.07], p <0.01). Anti-coagulation therapy using intravenous (IV) heparin and the chronic comorbidities of coronary artery disease and diabetes mellitus were also robust independent predictors of decreased survival. Conclusion This study was able to find an association between RBC transfusion and reduction in short-term (three months) and long-term (three years) survival. Those requiring IV heparin during the hospital stay were at an increased risk of requiring blood transfusion, and patients receiving IV heparin were also found to have a significant increase in mortality rates.