Trauma team activation criteria as predictors of patient disposition from the emergency department.

UNLABELLED: Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention. OBJECTIVES: To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED). METHODS: This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression. RESULTS: Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission. CONCLUSIONS: The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65."

The effects of the FDA warning on the use of droperidol by u.s. Emergency physicians.

OBJECTIVES: To determine if emergency physicians' (EP) use of droperidol has changed since the United States Food and Drag Administration (FDA) warning of December 2001 concerning QT interval prolongation, torsade de pointes, and sudden death; and to query EP opinions regarding droperidol before and after the FDA warning and regarding potential alternative drugs. METHODS: An internet-based survey was designed with questions regarding droperidol use in the emergency department (ED). Data collected included EP demographics, use of droperidol before and after the FDA warning, use of alternative drugs, and incidence of arrhythmias. A representative sample of EPs were contacted by e-mail and asked to complete the survey. RESULTS: A total of 2,000 e-mails resulted in 506 (25%) completed surveys. There was no second mailing. Responders' average years practicing was 12.6 ± 9.2. EP responders worked in private/community (n=278, 55%), academic/county (n=187, 37%), and HMO (n=41, 8%) hospitals. The. majority (n=455, 90%) used droperidol and were aware of the FDA warning (n=460, 91%). Droperidol was no longer available at 122 (24%) of the respondents' EDs as a result of the FDA warning. Prior to the FDA warning, EPs who had used droperidol used it as an antiemetic (n=408, 90%), for control of agitation (n=330, 73%), for treatment of headache (n=247, 54%), and for treatment of vertigo (n=106, 23%). After the FDA warning, 387 (85%) of EPs reported their use of droperidol had decreased or ceased altogether, and 68 (15%) always obtained an electrocardiogram prior to administration. Of those who used droperidol for agitation, 137 (42%) felt there were no other drugs with greater efficacy. Haloperidol was the most cited alternative agent (n=260, 79%) followed by benzodiazepines (n=223, 68%). Of those who used droperidol for antiemesis, 116 (28%) felt there were no other drugs with greater efficacy than droperidol; promethazine was the most cited alternative agent (n=260, 64%). Two (0.4%) EPs reported arrhythmias in patients who received droperidol. Only 37 (8%) EPs reported they were unconcerned with potential loss of droperidol from the market. CONCLUSION: Based on this survey, EP use of droperidol has decreased dramatically as a result of the FDA warning. However, EPs believe that there are few or no alternative antiemetic drugs that have an improved adverse effect profile.