An Observational Study of the Factor Xa Inhibitors Rivaroxaban and Apixaban as Reported to Eight Poison Centers.

STUDY OBJECTIVE: Rivaroxaban and apixaban are part of a new group of oral anticoagulants targeting factor Xa and approved by the Food and Drug Administration in 2011 and 2012. These oral anticoagulants are administered at fixed daily doses, without the need for laboratory-guided adjustments. There are limited data available on supratherapeutic doses or overdose of the oral Xa inhibitors. This study characterizes the clinical effect in patients exposed to rivaroxaban and apixaban. METHODS: A retrospective study collected data from 8 regional poison centers covering 9 states. Cases were initially identified by a search of the poison centers' databases for case mentions involving a human exposure to Xarelto, rivaroxaban, Eliquis, or apixaban. Inclusion criteria included single-substance exposure. Exclusion criteria were animal exposure, polysubstance exposure, or information call. Data for the study were collected by individual chart review, including case narratives, and compiled into a single data set. RESULTS: There were 223 patients: 124 (56%) were female patients, mean age was 60 years, and 20 were children younger than 12 years (9%). One hundred ninety-eight patients ingested rivaroxaban (89%) and 25 ingested apixaban (11%). Dose was reported in 182 rivaroxaban patients, with a mean dose of 64.5 mg (range 15 to 1,200 mg), and in 21 apixaban patients, with a mean dose of 9.6 mg (range 2.5 to 20 mg). For rivaroxaban, prothrombin time was measured in 49 patients (25%) and elevated in 7; partial thromboplastin time, measured in 49 (25%) and elevated in 5; and international normalized ratio, measured in 61 (31%) and elevated in 13. For apixaban, prothrombin time was measured in 6 patients (24%) and elevated in none; partial thromboplastin time, measure in 6 (24%) and elevated in none; and international normalized ratio, measured in 5 patients (20%) and elevated in none. Bleeding was reported in 15 patients (7%): 11 rivaroxaban and 4 apixaban. The site of bleeding was gastrointestinal (8), oral (2), nose (1), bruising (1), urine (1), and subdural (1). The subdural bleeding occurred after fall and head injury. All cases with bleeding involved long-term ingestions. Coagulation test results were normal in most patients with bleeding: prothrombin time 5 of 6 (83%), partial thromboplastin time 5 of 6 (83%), and international normalized ratio 5 of 9 (55%). Blood products were used in 7 rivaroxaban patients (1 suicide) and 3 apixaban patients. No bleeding or altered coagulation test results occurred in children, which all involved a one-time ingestion. All 12 suicide attempts involved rivaroxaban: altered coagulation test results occurred for 5 patients (42%), no bleeding occurred in any suicide attempt patient, 1 patient was treated with fresh frozen plasma (international normalized ratio 12.47), and dose by patient history did not predict risk of altered coagulation or bleeding. Two rivaroxaban patients experienced elevation of hepatic transaminase levels greater than 1,000 U/L. CONCLUSION: Bleeding after Xa inhibitor ingestion as a single agent is uncommon. Prothrombin time, partial thromboplastin time, or international normalized ratio may be elevated in a minority of cases but appears unreliable to measure risk of bleeding. Massive acute ingestion in suicide attempt may result in significant anticoagulation. Single exploratory ingestion by children was not associated with toxicity.

Creation of Three-dimensional Anatomic Models in Pediatric Surgical Patients Using Cross-sectional Imaging: A Demonstration of Low-cost Methods and Applications.

BACKGROUND: Pediatric surgery patients often present with complex congenital anomalies or other conditions requiring deep understanding of their intricate anatomy. Commercial applications and services exist for the conversion of cross-sectional imaging data into three-dimensional (3D) models for education and preoperative planning. However, the associated costs and lack of familiarity may discourage their use in centers with limited resources. The purpose of this report is to present a low-cost, reproducible method for generating 3D images to visualize patient anatomy. METHODS: De-identified DICOM files were obtained from the hospital PACS system in preparation for assorted pediatric surgical procedures. Using open-source visualization software, variations in anatomic structures were examined using volume rendering and segmentation techniques. Images were further refined using available editing tools or artificial intelligence-assisted software extensions. RESULTS: Using the described techniques we were able to obtain excellent visualization of desired structures and associated anatomic variations. Once structures were selected and modeled in 3D (segmentation), they could be exported as one of several 3D object file formats. These could then be retained for 3D printing, visualization in virtual reality, or as an anatomic reference during the perioperative period. Models may also be imported into commercial gaming engines for rendering under optimal lighting conditions and with enhanced detail. CONCLUSION: Pediatric surgeons are frequently tasked with the treatment of patients with complex and rare anomalies. Visualization and preoperative planning can be assisted by advanced imaging software at minimal to no cost, thereby facilitating enhanced understanding of these conditions in resource-limited environments. LEVEL OF EVIDENCE: V, Case Series, Description of Technique.

Integrating Artificial Intelligence Into the Visualization and Modeling of Three-Dimensional Anatomy in Pediatric Surgical Patients.

BACKGROUND: Pediatric surgeons often treat patients with complex anatomical considerations due to congenital anomalies or distortion of normal structures by solid organ tumors. There are multiple applications for three-dimensional visualization of these structures based on cross-sectional imaging. Recently, advances in artificial intelligence (AI) applications and graphics hardware have made rapid 3D modelling of individual structures within the body accessible to surgeons without sophisticated and expensive hardware. In this report, we provide an overview of these applications and their uses in preoperative planning for pediatric surgeons. METHODS: Deidentified DICOM files containing cross-sectional imaging of preoperative pediatric surgery patients were loaded from an institutional PACS database onto a secure PC with dedicated graphics and AI hardware (NVIDIA Geforce RTX 4070 laptop GPU). Visualization was obtained using an open-source imaging platform (3D Slicer). AI extensions to the platform were utilized to delineate the anatomy of interest. RESULTS: Segmentations of skeletal and visceral structures within a scan were obtained using the TotalSegmentator extension with an average processing time under 5 min. Additional AI modules were utilized for providing detailed mapping of the airways (AirwaySegmentation), lungs (Chest Imaging Platform), liver (SlicerLiver), or vasculature (SlicerVMTK). Other extensions were used for delineation of tumors within the hepatic parenchyma (MONAI Auto3DSeg) and hepatic vessels (RVesselX). CONCLUSION: AI algorithms for image interpretation and processors dedicated to AI functions have significantly decreased the technical and financial requirements for obtaining detailed three-dimensional images of patient anatomy. Models obtained using AI algorithms have potential applications in preoperative planning, surgical simulation, patient education, and training. LEVEL OF EVIDENCE: V, Case Series, Description of Technique.

Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections.

Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.

Bilateral near-infrared spectroscopy for detecting traumatic vascular injury.

BACKGROUND: Extremity wounds account for most battlefield injuries. Clinical examination may be unreliable by medics or first responders, and continuous assessment by experienced practitioners may not be possible on the frontline or during transport. Near-infrared spectroscopy (NIRS) provides continuous, noninvasive monitoring of tissue oxygen saturation (StO2), but its use is limited by inter-patient and intra-patient variability. We tested the hypothesis that bilateral NIRS partially addresses the variability problem and can reliably identify vascular injury after extremity trauma. MATERIALS AND METHODS: This prospective study consisted of 30 subjects: 20 trauma patients with extremity injury and 10 healthy volunteers. Bilateral StO2 tissue sensors were placed on the thenar eminence or medial plantar surface. Injured and non-injured extremities within the same patient (ΔStO2) were compared using Wilcoxon signed ranks test. Receiver operating characteristic curves were generated and areas under the curve (AUCs) were calculated for ΔStO2 of 6, 10, and 15. Values are expressed as median (interquartile range). RESULTS: Trauma patients were age 31 y (23 y), 85% male, with injury severity score of 9 (5). There were seven arterial and three venous injuries. Most involved the lower extremity (n = 16; 80%) and resulted from a penetrating mechanism (n = 14; 70%). ΔStO2 between limbs was 20.4 (10.4) versus 2.4 (3.0) (P < 0.001) for all patients with vascular injury versus patients and volunteers with no vascular injury. ΔStO2 reliably identified any vascular injury (AUC, 0.975; P < 0.001), whereas pulse examination alone or in combination with Doppler exam could detect only arterial injury. A ΔStO2 of 6 had the greatest sensitivity and specificity (AUC, 0.900; P < 0.001). CONCLUSIONS: Continuous monitoring of bilateral limbs with NIRS detects changes in perfusion resulting from arterial or venous injury and may offer advantages over serial manual measurements of pulses or Doppler signals. This technique may be most relevant in military and disaster scenarios or during transport, in which the ability to monitor limb perfusion is difficult or experienced clinical judgment is unavailable.

Evaluation of changes in poisoning in young children: 2000 to 2010.

OBJECTIVE: The nature of pediatric poisonings is dynamic, with changes occurring over time. We evaluated poisoning in children younger than 6 years for trends during an 11-year period regarding the substances involved in the poisoning, medical outcomes, and health care use. METHODS: This was retrospective study of poisoning in children younger than 6 years reported to 12 poison centers in 5 U.S. states for the years 2000 through 2010. Data abstracted included substance category involved in the exposure, age of patient, year of occurrence, location of patient management, and medical outcome. RESULTS: There were 2,577,036 poison exposures in children younger than 6 years, with a 12.4% increase from 210,270 poison exposures in 2000 to 236,425 poison exposures in 2010. There was a 33% increase (P < 0.05) in pharmaceutical related exposures in children younger than 6 years and a 2.8% decline in the number of nonpharmaceutical related exposures. Among those substance categories representing more than 1% of exposures, the only pharmaceutical showing decline was cough/cold preparations. There was a 53% increase in serious medical outcomes, including 119 deaths and a significant increase in health care facility use, primarily owing to pharmaceutical exposures. CONCLUSIONS: Poisoning in young children increasingly involves pharmaceuticals and is associated with an increased number of serious outcomes and children treated in a health care facility. We believe that these changes are related to increased availability of medications in the home and poison prevention education efforts should include a focus on the availability of these products to small children.

The Sinister Surgeon: Advanced Pediatric Minimally Invasive Surgery for Left-Handed Surgeons.

Purpose: Left-handed (LH) surgeons face unique challenges in their training and practice. Contrary to the historical and unjust perception of technical inferiority, LH surgeons can thrive under appropriate mentorship and support. Here, we describe modifications to pediatric minimally invasive surgeries to benefit the LH surgeon. Methods: The surgical approaches to common and complex pediatric surgical operations were modified to facilitate training of an LH pediatric surgical fellow. Results: Preoperative preparation, including communication with the operating room team, patient positioning, and provision of appropriate equipment, allowed the procedures to be accomplished in a safe and efficient manner. Conclusions: Modifying complex minimally invasive surgery to allow for use of the dominant hand is feasible and safe.

Improving Billing and Collections in a High-Volume Pediatric Surgery Practice: Denials-Based Approach.

BACKGROUND: Despite minimal coding and billing training, surgeons are frequently tasked with both in clinical practice. This often results in denials for reimbursement based on incorrect or insufficient documentation, and reduced collections for work performed. We sought to evaluate how to correct these deficits while improving reimbursement for the most frequently rejected procedures at a high-volume academic center. STUDY DESIGN: Hospital billing data were analyzed for a 4-year period (2018 to 2021) to determine the CPT code denials with the largest overall cost. The denials were then stratified according to payor, reason for denial, and preventability. Assigned ICD-10 codes were categorized based on specificity as related to the procedure. The distribution of denials according to ICD-10 specificity was evaluated using the chi-square test. RESULTS: A total of 8,833 denials representing $11,009,108 in billing were noted during the study period. The CPT code 44970 (laparoscopic appendectomy) was the code associated with the largest financial impact, representing 12.8% of the total denied amount ($1.41M). Of the 823 denials for CPT 44970, 93.3% were associated with nonspecific ICD-10 codes, whereas only 42.0% had been associated with procedure-specific ICD-10 codes. Of the patients with nonspecific codes, 80.7% of denials were due to criteria that could be remedied with supplemental information or timely filing, representing $1,059,968 in collections. CONCLUSIONS: This is the first study to systematically evaluate a pathway for using denial data to improve collections for work performed at a high-volume academic pediatric surgery practice. Using this methodology, targets for improvement in coding and/or documentation can be identified to improve the financial performance of a surgical department. This study also provides evidence that association with nonspecific diagnostic codes is correlated with initial denial of payment by insurance companies.

Utility of continuous pulse CO-oximetry for hemoglobin monitoring in pediatric patients with solid organ injuries at level 1 trauma centers: A pilot study.

INTRODUCTION: Hemorrhage is a major cause of preventable death in injured children. Monitoring after admission often requires multiple blood draws, which have been shown to be stressful in pediatric patients. The Rainbow-7 device is a continuous pulse CO-oximeter that measures multiple wavelengths of light, permitting continuous estimation of the total hemoglobin (Hb) level. The purpose of this study was to evaluate the utility of the noninvasive Hb measurement for monitoring pediatric trauma patients admitted with solid organ injury. METHODS: This is a prospective, dual-center, observational trial for patients younger than age 18 years admitted to a Level I pediatric trauma center. Following admission, blood was routinely measured as per current solid organ injury protocols. Noninvasive Hb monitoring was initiated after admission. Time-synced data for Hb levels were compared with that taken using blood draws. Data were evaluated using bivariate correlation, linear regression, and Bland-Altman analysis. RESULTS: Over a 1-year period, 39 patients were enrolled. The mean ± SD age was 11 ± 3.8 years. Forty-six percent (n = 18) of patients were male. The mean ± SD Injury Severity Score was 19 ± 13. The average change in Hb levels between laboratory measurements was -0.34 ± 0.95 g/dL, and the average change in noninvasive Hb was -0.12 ± 1.0 g/dL per measurement. Noninvasive Hb values were significantly correlated with laboratory measurements ( p < 0.001). Trends in laboratory Hb measurements were highly correlated with changes in noninvasive levels ( p < 0.001). Bland-Altman analysis demonstrated similar deviation from the mean throughout the range of Hb values, but the differences between measurements were increased by anemia, African American race, and elevated shock index, pediatric age-adjusted score and Injury Severity Score. CONCLUSION: Noninvasive Hb values demonstrated correlation with measured Hb concentration as isolated measurements and trends, although results were affected by skin pigmentation, shock, and injury severity. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive Hb monitoring may be a valuable adjunct for pediatric solid organ injury protocols. Further study is required to determine its role in management. LEVEL OF EVIDENCE: Dianostic Test or Criteria; Level III.

Venous thromboembolism after trauma: a never event?*.

OBJECTIVE: Rates of venous thromboembolism as high as 58% have been reported after trauma, but there is no widely accepted screening protocol. If Medicare adds venous thromboembolism to the list of "preventable complications," they will no longer reimburse for treatment, which could have devastating effects on many urban centers. We hypothesized that prescreening with a risk assessment profile followed by routine surveillance with venous duplex ultrasound that could identify asymptomatic venous thromboembolism in trauma patients. DESIGN: Prospective, observational trial with waiver of consent. SETTING: Level I trauma center intensive care unit. PATIENTS: At admission, 534 patients were prescreened with a risk assessment profile. INTERVENTIONS: Patients (n = 106) with risk assessment profile scores >10 were considered high risk and received routine screening venous duplex ultrasound within 24 hrs and weekly thereafter. RESULTS: In prescreened high-risk patients, 20 asymptomatic deep vein thrombosis were detected with venous duplex ultrasound (19%). An additional ten venous thromboembolisms occurred, including six symptomatic deep vein thrombosis and four pulmonary emboli, resulting in an overall venous thromboembolism rate of 28%. The most common risk factors discriminating venous thromboembolism vs. no venous thromboembolism were femoral central venous catheter (23% vs. 8%), operative intervention >2 hrs (77% vs. 46%), complex lower extremity fracture (53% vs. 32%), and pelvic fracture (70% vs. 47%), respectively (all p < .05). Risk assessment profile scores were higher in patients with venous thromboembolism (19 ± 6 vs. 14 ± 4, p = .001). Risk assessment profile score (odds ratio 1.14) and the combination of pelvic fracture requiring operative intervention >2 hrs (odds ratio 5.75) were independent predictors for development of venous thromboembolism. The rates of venous thromboembolism for no chemical prophylaxis (33%), unfractionated heparin (29%), dalteparin (40%), or inferior vena cava filters (20%) were not statistically different (p = .764). CONCLUSIONS: Medicare's inclusion of venous thromboembolism after trauma as a "never event" should be questioned. In trauma patients, high-risk assessment profile score and pelvic fracture with prolonged operative intervention are independent predictors for venous thromboembolism development, despite thromboprophylaxis. Although routine venous duplex ultrasound screening may not be cost-effective for all trauma patients, prescreening using risk assessment profile yielded a cohort of patients with a high prevalence of venous thromboembolism. In such high-risk patients, routine venous duplex ultrasound and/or more aggressive prophylactic regimens may be beneficial.

ECMO hospital volume and survival in congenital diaphragmatic hernia repair.

PURPOSE: This study examined survival in newborn patients after congenital diaphragmatic hernia (CDH) repair. METHODS: We analyzed the Kids' Inpatient Database Years 2000, 2003, and 2006 for patients admitted at fewer than 8 d of age undergoing CDH repair. We analyzed patient demographics, clinical characteristics, socioeconomic measures, hospital type, operative case volume, and survival using Fisher's exact test and a multivariate binary logistic regression model. RESULTS: Of 847 patients identified, most were male (61%) and white (57%), were treated at urban (99.8%) and teaching (96%) hospitals, and had private insurance (57%). Survival to discharge was 95% in non-extracorporeal membrane oxygenation (ECMO) patients versus 51% for those requiring ECMO (P < 0.0001). Univariate analysis revealed significantly lower survival rates in blacks, Medicaid patients, and patients undergoing repair after 7 d of life. Among ECMO patients, we noted higher survival rates at hospitals conducting four or more ECMO cases per year (66% versus 47%; P = 0.03). Multivariate analysis identified ECMO (hazards ratio [HR] 16.23, P < 0.001), CDH repair at >7 d of age (HR 2.70, P = 0.004), and ECMO patients repaired at hospitals performing <4 CDH ECMO cases per year (HR 3.59, P = 0.03) as independent predictors of mortality. CONCLUSIONS: We conclude that ECMO hospital volume is associated with survival in patients requiring ECMO for CDH repair.

Effect of Quarantine and Reopening Measures on Pediatric Trauma Admissions During the 2019 SARS-CoV2 Virus Pandemic.

BACKGROUND: Several studies have reported decreased trauma admissions and increased physical abuse in children resulting from stay-at-home measures. However, these studies have focused on a limited period after the implementation of lockdown policies. The purpose of this study was to examine the effect of quarantine and reopening initiatives on admissions for varying types of injuries in pediatric patients. STUDY DESIGN: Registry data for an urban Level I pediatric trauma center were evaluated from April 1, 2018, to March 30, 2021. A timeline of local shutdown and reopening measures was established and used to partition the data into 6-month intervals. Data about demographics and injury characteristics were compared with similar intervals in 2018 and 2019 using appropriate statistical methodology for categorical, parametric, and nonparametric data. RESULTS: A total of 3,110 patients met criteria for inclusion. A total of 1,106 patients were admitted the year after the closure of schools and nonessential businesses. Decreases in overall admissions and evaluations for suspected child abuse noted early in the pandemic were not sustained during shutdown or reopening periods. However, we observed a 77% increase in all-terrain vehicle injuries, along with a 59% reduction in sports injuries (chi-square [8, N = 3,110] = 49.7; p < 0.001). Significant shifts in demographic and payor status were also noted. CONCLUSIONS: This is the first study to comprehensively examine the effects of quarantine and reopening policies on admission patterns for a pediatric trauma center in a metropolitan area. Total admissions and child abuse evaluations were not impacted. If shutdown measures are re-instituted, preventative efforts should be directed towards ATV use and recreational activities.

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

BACKGROUND: Adverse drug events in the ambulatory care setting are not uncommon and can cause significant morbidity. Little research has been published on the management of adverse drug events involving insulin in the outpatient setting. OBJECTIVE: To analyze data on patients with unintentional therapeutic errors involving insulin managed by 9 regional poison control centers. METHODS: A retrospective search was performed for all records involving insulin at 9 poison centers, covering the population of 4 states for the years 2000-2009. A subgroup of the study population was selected with a reason for exposure of "unintentional-therapeutic error." RESULTS: There were 3819 insulin exposures reported, with an increase in the annual incidence of insulin exposures of 279% (from 170 to 645 patients/year) and a mean annual increase of 18%. Of the insulin exposures, 2584 were unintentional therapeutic errors (68%). The percentage of all insulin exposures that were unintentional therapeutic errors increased progressively, from 41% to 78%. There was a 495% increase in annual incidence of unintentional therapeutic errors involving insulin, with a mean annual increase of 28%. Unintentional therapeutic errors involving insulin occurred primarily in adults >40 years (73%), with 63% occurring in women. There was a pronounced increase in unintentional therapeutic errors involving insulin in the later evening hours, with 71% occurring between 1800 and 2400 and reaching a peak at 2200. The majority (n = 1803; 70%) of patients were managed in a non-health-care facility location, primarily their own residence. CONCLUSIONS: This is the first report of an increasing trend of insulin-related unintentional therapeutic errors in the ambulatory setting. Our study highlights a number of striking features, including: (1) a consistent and dramatic increase of unintentional therapeutic errors involving insulin over the 10-year period, (2) a high incidence of unintentional therapeutic errors involving insulin in the late evening hours, and (3) a high incidence of unintentional therapeutic errors involving insulin involving adults >40 years and females. With their 24/7 availability, poison centers appear to be an increasingly important resource for patients experiencing unintentional therapeutic errors involving insulin.

Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients.

BACKGROUND: Reduced heart rate variability (HRV) reflects autonomic dysfunction and can triage patients better than routine trauma criteria or vital signs. However, there is questionable specificity and no consensus measurement technique. The purpose of this study was to analyze whether factors that alter autonomic function affect the specificity of HRV for assessing traumatic injury. METHODS: We evaluated 216 hemodynamically stable adults (3:1 M:F; 97:3 blunt:penetrating; age 49 years ± 1 year, mean ± standard error) undergoing computed axial tomography (CT) scan to rule out traumatic brain injury (TBI). All were prospectively instrumented with a Mars Holter system (GE Healthcare, Milwaukee, WI). HRV was determined offline using time domain (standard deviation of normal-normal intervals, root-mean-square successive difference) and frequency domain (very low frequency [VLF], LF, wideband frequency, high frequency [HF], low to HF index ratio) calculations from 15-minute electrocardiogram and correlated with routine vital signs, mortality, TBI, morbidity, length of stay (LOS), and comorbidities. Significance (p ≤ 0.05) was determined using nonparametric analysis, Student's t test, analysis of variance, or multiple logistic regression. RESULTS: VLF alone predicted survival, severity of TBI, intensive care unit LOS, and hospital LOS (all p < 0.05). Beta-blockers or diabetes had no effect, whereas age, sedation, mechanical ventilation, spinal cord injury, and intoxication influenced one or more of the variables with age being the most powerful confounder (all p < 0.05). Except for the Glasgow Coma Scale, no other routine trauma or hemodynamic criteria correlated with any of these outcomes. CONCLUSIONS: Decreased VLF is an independent predictor of mortality and morbidity in hemodynamically stable trauma patients. Other time and other frequency domain variables correlated with some, but not all, outcomes. All were heavily influenced by factors that alter autonomic function, especially patient age.

Bispectral index to monitor propofol sedation in trauma patients.

BACKGROUND: This study tested the hypothesis that the bispectral index (BIS) is reliable relative to clinical judgment for estimating sedation level during daily propofol spontaneous awakening trials (SATs) in trauma patients. METHODS: This was a prospective observational trial with waiver of consent conducted in the intensive care unit of Level I trauma center in 94 mechanically ventilated trauma patients sedated with propofol alone or in combination with midazolam. BIS, Richmond Agitation Sedation Scale (RASS), electromyography, and heart rate variability, as a test of autonomic function, were measured for 45 minutes during daily SATs. Data were evaluated with analysis of variance, linear regression, and nonparametric tests. RESULTS: The BIS wave form coincided almost exactly with propofol on/off. Steady-state BIS correlated with RASS (p < 0.0001) and with propofol dose (p < 0.0001), but the strengths of association were relatively low (all r(2) < 0.5). BIS wave form was not altered by age, heart rate, or heart rate variability and was similar with propofol alone or propofol plus midazolam, but the presence of brain injury or the use of paralytics shifted the curve downward (both p < 0.001). The overall test characteristics for BIS versus RASS without neuromuscular blockade were sensitivity: 90% versus 77% (p = 0.034); specificity: 90% versus 75% (p = 0.021); positive predictive value: 90% versus 76% (p = 0.021), and negative predictive value: 90% versus 76% (p = 0.021). CONCLUSIONS: In the first trial in trauma patients and largest trial in any surgical population, the (1) BIS was reliable and has advantages over RASS of being continuous and objective, at least during a propofol SAT; (2) BIS interpretation remains somewhat subjective in patients receiving paralytic agents or with traumatic brain injury.

Use of antivenom for snakebites reported to United States poison centers.

UNLABELLED: In 2001, a new antivenin was introduced to the United States and became widely available in the snakebite season of 2002. We investigated what impact this may have had on snakebite treatment and medical outcome. METHOD: The study used a retrospective review of all snakebites to humans reported to the National Poison Center Database System from 2000 to 2007. RESULTS: During the 8 years, there were 37,760 snakebites, with a mean of 4720 bites per year. There was a 27% increase in bites reported to a Poison center for the 8-year period and an overall 13.5% increase in the use of antivenin. The 2 categories primarily responsible for the increased use of antivenin were copperhead and crotaline-unknown. Rattlesnake bites remained the category most frequently treated with antivenin with a mean 52.5% treatment rate and only moderate increase for the 8 years. There was no change in the percentage or number of patients with a major outcome (mean, 3.8%) or death (mean, 0.5%). There was a decrease in patients with a minor outcome and an increase in patients with a moderate outcome. DISCUSSION: The new antivenin is reported to have a reduced potential for adverse reactions. This may have had a role in the decision of which snakebite victims received antivenin. CONCLUSION: With the introduction of a new antivenin, there has been a dramatic increase in the number of snakebite patients treated with antivenin. This has been most noticeable in snake bite categories that were less frequently treated with antivenin in the past.

Emergency department assessment and management of facial trauma from war-related injuries.

Facial trauma related to combat injury is of increasing prevalence and complex in nature when associated with the multiply injured trauma victim. Although rarely life-threatening, the treating physician must be aware of the presence of facial trauma and its associated injuries to seamlessly treat the combat casualty in accordance to the Advanced Trauma Life Support protocol while maintaining the armed forces' ultimate goals of returning "the greatest possible number of soldiers to combat and the preservation of life, limb and eyesight in those who must be evacuated." To this end, the treating physician must maintain a high index of suspicion for injury and have various maneuvers available to handle immediate threats to life, limb, or sight. This article will review the proper emergency department assessment and management of prevalent injuries associated with war-related facial trauma.

Predeployment mass casualty and clinical trauma training for US Army forward surgical teams.

Since the beginning of the program in 2002, 84 Forward Surgical Teams (FSTs) have rotated through the Army Trauma Training Center (ATTC) at the University of Miami/Ryder Trauma Center including all those deployed to Iraq and Afghanistan. The purpose of this study was to provide the latest updates of our experience with FSTs at the ATTC. Before deployment, each FST participates in a 2-week training rotation at the ATTC. The rotation is divided into 3 phases. Phase 1 is to refresh FST knowledge regarding the initial evaluation and management of the trauma patient. Phase 2 is the clinical phase and is conducted entirely at the Ryder Trauma Center. The training rotation culminates in phase 3, the Capstone exercise. During the Capstone portion of their training, the entire 20-person FST remains at the Ryder Trauma Center and is primarily responsible for the evaluation and resuscitation of all patients arriving over a 24-hour period. Subject awareness concerning their role within the team improved from 71% to 95%, indicating that functioning as a team in the context of the mass casualty training exercise along with clinical codes was beneficial. The clinical component of the rotation was considered by 47% to be the most valuable aspect of the training. Our experience strongly suggests that a multimodality approach is beneficial for preparing a team of individuals with minimal combat (or trauma) experience for the rigors of medical care and triage on the battlefield. The data provided by participants rotating through the ATTC show that through clinical exposure and simulation over a 2-week period, FST performance is optimized by defining provider roles and improving communication. The mass casualty training exercise is a vital component of predeployment training that participants feel is valuable in preparing them for the challenges that lay ahead.

2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report.

Introduction: This is the 37th Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of 1 January, 2019, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 6.52 [6.12, 8.68] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system.Methods: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure.Results: In 2019, 2,573,180 closed encounters were logged by NPDS: 2,148,141 human exposures, 68,711 animal exposures, 351,163 information requests, 5,078 human confirmed nonexposures. Total encounters showed a 1.70% increase from 2018, while health care facility (HCF) human exposure cases remained nearly steady with a slight decrease of 0.495%. All information requests decreased by 4.58%, medication identification (Drug ID) requests decreased by 29.7%, and human exposure cases increased by 2.30%. Human exposures with less serious outcomes have decreased 2.08% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.61% per year since 2000.Consistent with the previous year, the top 5 substance classes most frequently involved in all human exposures were analgesics (11.0%), household cleaning substances (7.13%), cosmetics/personal care products (6.16%), antidepressants (5.32%), and sedatives/hypnotics/antipsychotics (5.21%). As a class, antidepressant exposures increased most rapidly, by 1,957 cases/year (3.90%/year) over the past 10 years for cases with more serious outcomes.The top 5 most common exposures in children age 5 years or less were cosmetics/personal care products (11.4%), household cleaning substances (10.5%), analgesics (8.97%), foreign bodies/toys/miscellaneous (7.17%), and dietary supplements/herbals/homeopathic (5.06%). Drug identification requests comprised 13.4% of all information contacts. NPDS documented 2,619 human exposures resulting in death; 2,048 (78.2%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory).Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information contacts. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health.