Is Lateral Decubitus or Upright Positioning Optimal for Lumbar Puncture Success in a Teaching Hospital?

BACKGROUND: Lumbar puncture is a common procedure performed by emergency physicians and trainees. The optimal patient positioning for lumbar puncture procedures has not been studied adequately. OBJECTIVES: We performed a prospective randomized study in an urban, level I academic trauma center. Patients of all ages were included. Patients were randomized to either lateral decubitus or upright positioning. Patient demographic characteristics, level of physician training and experience, number of needle insertions and redirections, need for repositioning, alternative operator use, and laboratory results of the cerebrospinal fluid were recorded. We compared the success rate of each position as our primary outcome measure. We also evaluated number of needle insertions and re-directions and success rates based on experience and patient age. RESULTS: A total of 116 patients were enrolled, with 55 patients assigned to lateral decubitus and 61 to upright position for initial lumbar puncture attempt. Spinal fluid was obtained successfully in 47 of the lateral decubitus group (85.5%; 95% CI 73.8-92.4%) vs. 49 (80.3%; 95% CI 68.7-88.4%) in the upright assignment group. Comparable results were also obtained for first-pass success, number of failures, and number of bloody taps. Postgraduate year 2 residents or those with 31-50 previous lumbar punctures had the highest success rates at 94.3% (95% CI 81.2-98.4%) and 90.3% (95% CI 75.1-96.7%), respectively. CONCLUSIONS: Lateral decubitus and upright positioning for emergency lumbar puncture yielded equal success rates in emergency physicians and trainees.

Patient controlled analgesia for the management of acute pain in the emergency department: A systematic review.

BACKGROUND: The most common presenting complaint to the emergency department (ED) is pain. Several studies have shown that a large proportion of ED patients either receive no or sub-optimal analgesia. Patient-controlled analgesia (PCA) pumps used in the post-operative setting has shown to decrease total opioid consumption and has increased patient and nurse satisfaction. OBJECTIVE: The purpose of this systematic review was to evaluate clinical trials that have used PCAs in the ED setting, to evaluate safety and efficacy as well as patient and healthcare provider experience. METHODS: A search of PubMed, MEDLINE, and the Cochrane Database was conducted using the MESH search terms emergency department, patient-controlled analgesia, and acute pain up to September 2021. These terms were searched in all fields of publication and were limited to the English-language articles, clinical "human" studies, and studies that included the use of patient-controlled analgesia in the setting of the emergency department. RESULTS: The search initially identified 227 potentially relevant articles and a total of 10 studies met criteria for inclusion. ED use of PCA therapy was associated with increased patient satisfaction, decreased pain scores, and an overall increase in opioid consumption. CONCLUSION: The quality, the differences in study methods and outcome measures used, and heterogeneity of the studies performed to date do not provide adequate evidence to support its widespread use in the ED. Well-designed studies conducted in the ED are still needed to evaluate the ideal patient population to whom these PCAs may provide the most benefit as well as a robust cost-analysis to ensure feasibility of use in the future.

Concussion severity and functional outcome using biomarkers in children and youth involved in organized sports, recreational activities and non-sport related incidents.

This prospective multicenter study evaluated differences in concussion severity and functional outcome using glial and neuronal biomarkers glial Fibrillary Acidic (GFAP) and Ubiquitin C-terminal Hydrolase (UCH-L1) in children and youth involved in non-sport related trauma, organized sports, and recreational activities. Children and youth presenting to three Level 1 trauma centersfollowing blunt head trauma with a GCS 15 with a verified diagnosis of a concussion were enrolled within 6 hours of injury. Traumatic intracranial lesions on CT scan and functional outcome within 3 months of injury were evaluated. 131 children and youth with concussion were enrolled, 81 in the no sports group, 22 in the organized sports group and 28 in the recreational activities group. Median GFAP levels were 0.18, 0.07, and 0.39 ng/mL in the respective groups (p = 0.014). Median UCH-L1 levels were 0.18, 0.27, and 0.32 ng/mL respectively (p = 0.025). A CT scan of the head was performed in 110 (84%) patients. CT was positive in 5 (7%), 4 (27%), and 5 (20%) patients, respectively. The AUC for GFAP for detecting +CT was 0.84 (95%CI 0.75-0.93) and for UCH-L1 was 0.82 (95%CI 0.71-0.94). In those without CT lesions, elevations in UCH-L1 were significantly associated with unfavorable 3-month outcome. Concussions in the 3 groups were of similar severity and functional outcome. GFAP and UCH-L1 were both associated with severity of concussion and intracranial lesions, with the most elevated concentrations in recreational activities .

Predicting Clinical Outcomes 7-10 Years after Severe Traumatic Brain Injury: Exploring the Prognostic Utility of the IMPACT Lab Model and Cerebrospinal Fluid UCH-L1 and MAP-2.

BACKGROUND: Severe traumatic brain injury (TBI) is a major contributor to disability and mortality in the industrialized world. Outcomes of severe TBI are profoundly heterogeneous, complicating outcome prognostication. Several prognostic models have been validated for acute prediction of 6-month global outcomes following TBI (e.g., morbidity/mortality). In this preliminary observational prognostic study, we assess the utility of the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) Lab model in predicting longer term global and cognitive outcomes (7-10 years post injury) and the extent to which cerebrospinal fluid (CSF) biomarkers enhance outcome prediction. METHODS: Very long-term global outcome was assessed in a total of 59 participants (41 of whom did not survive their injuries) using the Glasgow Outcome Scale-Extended and Disability Rating Scale. More detailed outcome information regarding cognitive functioning in daily life was collected from 18 participants surviving to 7-10 years post injury using the Cognitive Subscale of the Functional Independence Measure. A subset (n = 10) of these participants also completed performance-based cognitive testing (Digit Span Test) by telephone. The IMPACT lab model was applied to determine its prognostic value in relation to very long-term outcomes as well as the additive effects of acute CSF ubiquitin C-terminal hydrolase-L1 (UCH-L1) and microtubule associated protein 2 (MAP-2) concentrations. RESULTS: The IMPACT lab model discriminated favorable versus unfavorable 7- to 10-year outcome with an area under the receiver operating characteristic curve of 0.80. Higher IMPACT lab model risk scores predicted greater extent of very long-term morbidity (ß = 0.488 p = 0.000) as well as reduced cognitive independence (ß = - 0.515, p = 0.034). Acute elevations in UCH-L1 levels were also predictive of lesser independence in cognitive activities in daily life at very long-term follow-up (ß = 0.286, p = 0.048). Addition of two CSF biomarkers significantly improved prediction of very long-term neuropsychological performance among survivors, with the overall model (including IMPACT lab score, UCH-L1, and MAP-2) explaining 89.6% of variance in cognitive performance 7-10 years post injury (p = 0.008). Higher acute UCH-L1 concentrations were predictive of poorer cognitive performance (ß = - 0.496, p = 0.029), whereas higher acute MAP-2 concentrations demonstrated a strong cognitive protective effect (ß = 0.679, p = 0.010). CONCLUSIONS: Although preliminary, results suggest that existing prognostic models, including models with incorporation of CSF markers, may be applied to predict outcome of severe TBI years after injury. Continued research is needed examining early predictors of longer-term outcomes following TBI to identify potential targets for clinical trials that could impact long-ranging functional and cognitive outcomes.

Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions.

OBJECTIVES: Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions. METHODS: This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 µg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. RESULTS: Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group. CONCLUSIONS: Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

Ketamine for acute suicidality in the emergency department: A systematic review.

INTRODUCTION: There are no emergent pharmaceutical interventions for acute suicidal ideation, a common presenting complaint in the ED. Ketamine is a NMDA agonist frequently used by ED physicians for sedation and analgesia. Prior evidence from studies conducted in inpatient psychiatry units suggests that ketamine may have a role in alleviating treatment-resistant depression as well as suicidal ideation. METHODS: PubMed, MEDLINE, and Cochrane reviews were queried for articles related to keywords ketamine, suicidality, suicidal ideation, and emergency department/room. Relevant articles were selected and reviewed by two separate authors. RESULTS: Three relevant, prospective studies were identified with a mean sample size of 25.7. Each was performed using 0.2 mg/kg ketamine for individuals receiving active treatment. Each study reported a decrease in depressive symptoms among those receiving ketamine. One study reported a significant reduction in SI when compared to placebo at 90 min that became non-significant by 230 min. No significant adverse events were reported in any study. CONCLUSION: Current evidence suggests that ketamine is a promising, safe potential intervention for acute suicidality in the ED. Convincing evidence for efficacy of ketamine for acute suicidal ideation remains lacking, and this promising potential intervention should be further investigated.

Does Receiving a Text Message Reminder Increase Follow-up Compliance After Discharge From a Pediatric Emergency Department?

OBJECTIVES: Compliance with recommended follow-up from the pediatric emergency department (PED) has been shown to be poor. This study evaluated whether a text message reminder to the caregivers after discharge from the PED improved compliance with recommended primary care follow-up. METHODS: This was a blinded randomized control trial conducted at a level 1 pediatric trauma center. The intervention was a text message sent to the caregiver within 24 hours of discharge from the PED reminding them to follow up with their primary care doctor. Patients were eligible if the caregiver had text message capability on their cellular phones, they were currently established patients of the organization's Pediatric Faculty Practice, they were discharged home from the PED, and they were referred for follow-up within 1 week of discharge by the pediatric emergency physician. After informed consent, pediatric patients were randomized to either an intervention group (text message appointment reminder) or a control group (standard scheduling with no reminder). The patient, treating physician, and primary care outpatient center were blinded to the group assignment. Enrollment occurred 24 hours per day and 7 days per week. RESULTS: There were 123 patients enrolled in the study, 62 patients randomized to the control group (standard scheduling) and 61 randomized to the intervention group (text message appointment reminder). Of the patients, 58% were male and 42% were female, with the average age of the patients being 2.2 years (SD, 2.8). The majority of patients were seen in the PED on a weekday, with 24% presenting on a weekend. Only 28% of patients completed the recommended follow-up, and the average time from PED discharge to follow-up was 6 days (SD, 4.2; range, 0-17 days). There was no significant difference in follow-up in the standard treatment group (19/62, 31%) versus the text message intervention group (16/61, 26%) (P = 0.69; rate ratio, 0.94; 95% confidence interval, 0.75-1.18). When we assessed other variables, we found that parents of younger children were more likely to follow up as recommended by the pediatric ED physician. Of those who were compliant with follow-up, we found a mean age of 1.3 years (SD, 2.0; range, 0.8-9.1) versus 2.6 years (SD, 3.0; range, 0.08-15.3) for those who were not compliant with follow-up (P = 0.02). CONCLUSIONS: In this randomized controlled study, a text message reminder to caregivers did not improve compliance for PED patients. However, caregivers of younger children were more likely to complete follow-up as recommended by the PED physician compared with caregivers of older children.

Evaluation of an Online Educational Tool to Improve Postresuscitation Debriefing in the Emergency Department.

OBJECTIVE: Postresuscitation debriefing (PRD) addresses Accreditation Council for Graduate Medical Education core competencies and is recommended by the American Heart Association. Postresuscitation debriefing improves resuscitation outcomes, promotes team morale, supports emotional well-being, and reduces burnout. Despite these benefits, PRD occurs infrequently. Commonly cited barriers to PRD include lack of training and comfort in facilitating PRD. We are unaware of any video-based educational tools that train physicians in PRD. We aimed to evaluate the impact of an educational tool on the frequency of PRD using a before- and after-study design. METHODS: We created and distributed a 20-minute, video-based educational tool via youtube.com on PRD to pediatric emergency medicine (EM) fellows, pediatric EM attendings, senior EM residents, and EM attending physicians. Participants completed web-based surveys before, immediately after, and 3 months after watching the tool. We analyzed the effects of participation on PRD knowledge, comfort conducting PRD, and frequency of PRD performance. RESULTS: Thirty-five (63%) of 56 participants completed all 3 surveys. Participation in our study showed significant improvements in reported frequency of performing PRD (23% presurvey, 38% follow-up survey; 95% confidence interval [CI], 2%-29%; P = 0.03), perceived knowledge of PRD (odds ratio, 6.1; 95% CI, 3.05-12.29; P < 0.001), and comfort in conducting PRD (odds ratio, 3.7; 95% CI, 1.96-7.03; P < 0.001). Most respondents (94%) reported that the tool was worthwhile. Most (83%) would recommend the tool to colleagues, and 86% reported positive effects on their teams with PRD. CONCLUSIONS: Implementation of a video-based educational tool on PRD in the emergency department was associated with increased provider report of PRD frequency, knowledge, and comfort level.

A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild-to-Moderate Traumatic Brain Injury.

OBJECTIVES: Translingual neurostimulation (TLNS) studies indicate improved outcomes in neurodegenerative disease or spinal cord injury patients. This study was designed to assess the safety and efficacy of TLNS plus targeted physical therapy (PT) in people with a chronic balance deficit after mild-to-moderate traumatic brain injury (mmTBI). MATERIALS AND METHODS: This international, multicenter, randomized study enrolled 122 participants with a chronic balance deficit who had undergone PT following an mmTBI and had plateaued in recovery. Randomized participants received PT plus either high-frequency pulse (HFP; n = 59) or low-frequency pulse (LFP; n = 63) TLNS. The primary efficacy and safety endpoints were the proportion of sensory organization test (SOT) responders (SOT composite score improvement of ≥15 points) and fall frequency after five weeks of treatment, respectively. RESULTS: The proportion of SOT responders was significant in the HFP + PT (71.2%) and LFP + PT (63.5%) groups compared with baseline (p < 0.0005). For the pooled population, the SOT responder rate was 67.2% (p < 0.00005), and there were clinically and statistically significant improvements in SOT composite scores after two and five weeks (p < 0.0005). Both groups had reductions in falls and headache disability index scores. Mean dynamic gait index scores in both groups also significantly increased from baseline at weeks 2 and 5. CONCLUSIONS: Significant improvements in balance and gait, in addition to headaches, sleep quality, and fall frequency, were observed with TLNS plus targeted PT; in participants who had a chronic balance deficit following an mmTBI and had plateaued on prior conventional physiotherapy.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion.

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures.

OBJECTIVE: To determine if prehospital identification of sepsis will affect time to Centers for Medicare and Medicaid services (CMS) sepsis core measures and improve clinical outcomes. METHODS: We conducted a retrospective cohort study among septic patients who were identified as "sepsis alerts" in the emergency department (ED). Metrics including time from ED registration to fluid resuscitation, blood cultures, serum lactate draws, and antibiotics administration were compared between those who had pre-arrival notification by EMS versus those that did not. Additionally, outcomes such as mortality and intensive care unit (ICU) admission were recorded. RESULTS: Of the 272 total patients, 162 had pre-arrival notification (prehospital sepsis alerts) and 110 did not. The prehospital sepsis alert group had significantly lower times to intravenous fluid administration (6 min 95%CI 4-9 min vs 41 min 95%CI 24-58 min, p < 0.001), blood cultures drawn (12 min 95%CI 10-14 min vs 34 min 95%CI 20-48 min, p = 0.003), lactate levels drawn (12 min 95%CI 10-15 min vs 34 min 95%CI 20-49 min, p = 0.003), and administration of antibiotics (33 min 95%CI 26-40 min vs 61 min 95%CI 44-78 min, p = 0.004). Patients with prehospital sepsis alerts also had a higher admission rate (100% vs 95%, p = 0.006), and a lower ICU admission rate (33% vs 52%, p = 0.003). There was no difference in mortality (11% vs 14%, p = 0.565) between groups. CONCLUSIONS: Prehospital sepsis alert notification may decrease time to specific metrics shown to improve outcomes in sepsis.

Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients.

BACKGROUND: End-tidal carbon dioxide (EtCO2) measurement has been shown to have prognostic value in acute trauma. OBJECTIVE: Evaluate the association of prehospital EtCO2 and in-hospital mortality in trauma patients and to assess its prognostic value when compared to traditional vital signs. METHODS: Retrospective, cross-sectional study of patients transported by a single EMS agency to a level one trauma center. We evaluated initial out-of-hospital vital signs documented by EMS personnel including EtCO2, respiratory rate (RR), systolic BP (SBP), diastolic BP (DBP), pulse (P), and oxygen saturation (O2) and hospital data. The main outcome measure was mortality. RESULTS: 135 trauma patients were included; 9 (7%) did not survive. The mean age of patients was 40 (SD17) [Range 16-89], 97 (72%) were male, 76 (56%) were admitted to the hospital and 15 (11%) went to the ICU. The mean EtCO2 level was 18 mmHg (95%CI 9-28) [Range 5-41] in non-survivors compared to 34 mmHg (95%CI 32-35) [Range 11-51] in survivors. The area under the ROC curve (AUC) for EtCO2 in predicting mortality was 0.84 (0.67-1.00) (p = 0.001), RR was 0.82 (0.63-1.00), SBP was 0.72 (0.49-0.96), DBP was 0.72 (0.47-0.97), pulse was 0.51 (0.26-0.76), and O2 was 0.64 (0.37-0.91). Cut-off values at 30 mmHg yielded sensitivity = 89% (51-99), specificity = 68% (59-76), PPV = 13% (6-24) and NPV = 99% (93-100) for predicting mortality. There was no correlation between RR and EtCO2 (correlation 0.16; p = 0.06). CONCLUSION: We found an inverse association between prehospital EtCO2 and mortality. This has implications for improving triage and assisting EMS in directing patients to an appropriate trauma center.

A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.

OBJECTIVE: To determine the utility of a prehospital sepsis screening protocol utilizing systemic inflammatory response syndrome (SIRS) criteria and end-tidal carbon dioxide (ETCO2). METHODS: We conducted a prospective cohort study among sepsis alerts activated by emergency medical services during a 12 month period after the initiation of a new sepsis screening protocol utilizing ≥2 SIRS criteria and ETCO2 levels of ≤25 mmHg in patients with suspected infection. The outcomes of those that met all criteria of the protocol were compared to those that did not. The main outcome was the diagnosis of sepsis and severe sepsis. Secondary outcomes included mortality and in-hospital lactate levels. RESULTS: Of 330 sepsis alerts activated, 183 met all protocol criteria and 147 did not. Sepsis alerts that followed the protocol were more frequently diagnosed with sepsis (78% vs 43%, P < .001) and severe sepsis (47% vs 7%, P < .001), and had a higher mortality (11% vs 5%, P = .036). Low ETCO2 levels were the strongest predictor of sepsis (area under the ROC curve (AUC) of 0.99, 95% CI 0.99-1.00; P < .001), severe sepsis (AUC 0.80, 95% CI 0.73-0.86; P < .001), and mortality (AUC 0.70, 95% CI 0.57-0.83; P = .005) among all prehospital variables. Sepsis alerts that followed the protocol had a sensitivity of 90% (95% CI 81-95%), a specificity of 58% (95% CI 52-65%), and a negative predictive value of 93% (95% CI 87-97%) for severe sepsis. There were significant associations between prehospital ETCO2 and serum bicarbonate levels (r = 0.415, P < .001), anion gap (r = -0.322, P < .001), and lactate (r = -0.394, P < .001). CONCLUSION: A prehospital screening protocol utilizing SIRS criteria and ETCO2 predicts sepsis and severe sepsis, which could potentially decrease time to therapeutic intervention.

The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED.

OBJECTIVE: This study assesses outcome in pediatric patients with skin abscess using the LOOP compared to the standard incision and drainage (I&D) with packing method. METHODS: This retrospective study used ICD-9 codes to identify pediatric patients aged 0 to 17 years with a skin abscess presenting to a level I pediatric trauma emergency department (ED). Patients requiring surgical debridement were excluded; as were patients with abscesses on the face, scalp, hands or feet. The primary outcome was failure rate, defined as those requiring admission, intravenous antibiotics, or repeat drainage. RESULTS: Over a 1-year period there were 233 pediatric abscesses identified: 79 cases (34%) treated with the LOOP technique and 154 cases with standard I&D (66%). The overall mean age of patients was 6.2 yrs: children in the LOOP group were younger than those in the standard group, 4.4 vs 7.1 years respectively (P=.001). Abscess location also differed between the two groups; however they had a similar gender distribution and mean temperature. Of the cases identified by chart review, clinical outcome could be assessed in 143 patients (61%): 52 (36%) patients with LOOP vs 91 (64%) with I&D. Failure rate was 1.4% in the LOOP group and 10.5% in the standard I&D (P<.030). CONCLUSION: There was a significant difference in failure rate between the LOOP and the standard I&D groups. A prospective randomized trial is needed to confirm these results, but this novel technique shows promise as an alternative to I&D with packing in the management of skin abscesses in pediatric ED patients.

Biomarkers improve clinical outcome predictors of mortality following non-penetrating severe traumatic brain injury.

OBJECTIVE: This study assessed whether early levels of biomarkers measured in CSF within 24-h of severe TBI would improve the clinical prediction of 6-months mortality. METHODS: This prospective study conducted at two Level 1 Trauma Centers enrolled adults with severe TBI (GCS ≤8) requiring a ventriculostomy as well as control subjects. Ventricular CSF was sampled within 24-h of injury and analyzed for seven candidate biomarkers (UCH-L1, MAP-2, SBDP150, SBDP145, SBDP120, MBP, and S100B). The International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) scores (Core, Extended, and Lab) were calculated for each patient to determine risk of 6-months mortality. The IMPACT models and biomarkers were assessed alone and in combination. RESULTS: There were 152 patients enrolled, 131 TBI patients and 21 control patients. Thirty six (27 %) patients did not survive to 6 months. Biomarkers were all significantly elevated in TBI versus controls (p < 0.001). Peak levels of UCH-L1, SBDP145, MAP-2, and MBP were significantly higher in non-survivors (p < 0.05). Of the seven biomarkers measured at 12-h post-injury MAP-2 (p = 0.004), UCH-L1 (p = 0.024), and MBP (p = 0.037) had significant unadjusted hazard ratios. Of the seven biomarkers measured at the earliest time within 24-h, MAP-2 (p = 0.002), UCH-L1 (p = 0.016), MBP (p = 0.021), and SBDP145 (0.029) had the most significant elevations. When the IMPACT Extended Model was combined with the biomarkers, MAP-2 contributed most significantly to the survival models with sensitivities of 97-100 %. CONCLUSIONS: These data suggest that early levels of MAP-2 in combination with clinical data provide enhanced prognostic capabilities for mortality at 6 months.

Prehospital end-tidal carbon dioxide differentiates between cardiac and obstructive causes of dyspnoea.

BACKGROUND: Differentiating between cardiac and obstructive causes for dyspnoea is essential for proper management, but is difficult in the prehospital setting. OBJECTIVE: To assess if prehospital levels of end-tidal carbon dioxide (ETCO2) differed in obstructive compared to cardiac causes of dyspnoea, and could suggest one diagnosis over the other. METHODS: We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period who were diagnosed with either obstructive pulmonary disease or congestive heart failure (CHF) by ICD-9 codes. Initial prehospital vital signs, including ETCO2, were recorded. Records were linked by manual archiving of emergency medical services and hospital data. RESULTS: There were 106 patients with a diagnosis of obstructive or cardiac causes of dyspnoea that had prehospital ETCO2 levels measured during the study period. ETCO2 was significantly lower in patients diagnosed with CHF (31 mm Hg 95% CI 27 to 35) versus obstructive pulmonary disease (39 mm Hg 95% CI 35 to 42; p<0.001). Lower ETCO2 levels predicted CHF, with an area under the Receiver Operating Characteristics Curve of 0.70 (95% CI 0.60 to 0.81). Using ETCO2 <40 mm Hg as a cut-off, the sensitivity for predicting heart failure was 93% (95% CI 88% to 98%), the specificity was 43% (95% CI 33% to 52%), the positive predictive value was 38% (95% CI 29% to 48%), and the negative predictive value was 94% (95% CI 89% to 99%). CONCLUSIONS: Lower levels of ETCO2 were associated with CHF, and may serve as an objective diagnostic adjunct to predict this cause of dyspnoea in the prehospital setting.

Systematic review and meta-analysis of noninvasive cranial nerve neuromodulation for nervous system disorders.

OBJECTIVE: To systematically review the medical literature and comprehensively summarize clinical research done on rehabilitation with a novel portable and noninvasive electrical stimulation device called the cranial nerve noninvasive neuromodulator in patients suffering from nervous system disorders. DATA SOURCES: PubMed, MEDLINE, and Cochrane Database of Systematic Reviews from 1966 to March 2013. STUDY SELECTION: Studies were included if they recruited adult patients with peripheral and central nervous system disorders, were treated with the cranial nerve noninvasive neuromodulator device, and were assessed with objective measures of function. DATA EXTRACTION: After title and abstract screening of potential articles, full texts were independently reviewed to identify articles that met inclusion criteria. DATA SYNTHESIS: The search identified 12 publications: 5 were critically reviewed, and of these 5, 2 were combined in a meta-analysis. There were no randomized controlled studies identified, and the meta-analysis was based on pre-post studies. Most of the patients were individuals with a chronic balance dysfunction. The pooled results demonstrated significant improvements in the dynamic gait index postintervention with a mean difference of 3.45 (95% confidence interval, 1.75-5.15; P<.001), Activities-specific Balance Confidence scale with a mean difference of 16.65 (95% confidence interval, 7.65-25.47; P<.001), and Dizziness Handicap Inventory with improvements of -26.07 (95% confidence interval, -35.78 to -16.35; P<.001). Included studies suffered from small sample sizes, lack of randomization, absence of blinding, use of referral populations, and variability in treatment schedules and follow-up rates. CONCLUSIONS: Given these limitations, the results of the meta-analysis must be interpreted cautiously. Further investigation using rigorous randomized controlled trials is needed to evaluate this promising rehabilitation tool for nervous system disorders.

The sixth vital sign: prehospital end-tidal carbon dioxide predicts in-hospital mortality and metabolic disturbances.

OBJECTIVE: To determine the ability of prehospital end-tidal carbon dioxide (ETCO2) to predict in-hospital mortality compared to conventional vital signs. METHODS: We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period. Included patients had ETCO2 recorded in addition to initial vital signs. The main outcome was death at any point during hospitalization. Secondary outcomes included laboratory results and admitting diagnosis. RESULTS: Of 1328 records reviewed, hospital discharge data, ETCO2, and all 6 prehospital vital signs were available in 1088 patients. Low ETCO2 levels were the strongest predictor of mortality in the overall group (area under the receiver operating characteristic curve (AUC of 0.76, 95% confidence interval [CI] 0.66-0.85), as well as subgroup analysis excluding prehospital cardiac arrest (AUC of 0.77, 95% CI 0.67-0.87). The sensitivity of abnormal ETCO2 for predicting mortality was 93% (95% CI 79%-98%), the specificity was 44% (95% CI 41%-48%), and the negative predictive value was 99% (95% CI 92%-100%). There were significant associations between ETCO2 and serum bicarbonate levels (r = 0.429, P < .001), anion gap (r = -0.216, P < .001), and lactate (r = -0.376, P < .001). CONCLUSION: Of all prehospital vital signs, ETCO2 was the most predictive and consistent for mortality, which may be related to an association with metabolic acidosis.

Timing and causes of death to 1 year among children presenting to emergency departments.

BACKGROUND AND OBJECTIVES: A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. METHODS: We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow-up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1-year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. RESULTS: There were 546,044 children during the 6-year period. The 1-year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. CONCLUSIONS: The 1-year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients.

The i-gel® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID-19 pandemic.

Objective: Unlike randomized controlled trials, practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID-19 pandemic-driven shift from endotracheal intubation (ETI) to the i-gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first-pass success and timing to successful airway placement between ETI and the i-gel® SGA under extenuating circumstances. Methods: This pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non-trauma-related conditions. Data from EMS records were extracted over 2 years, 12 months pre-pandemic, and 12 months post-pandemic. During the pre-COVID-19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post-pandemic paramedics were mandated to utilize i-gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group). Results: There were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First-pass success was significantly higher with SGA 96% (92%-99%) than ETI 68% (57%-78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first-pass success was significantly shorter in the SGA group (5.9 min [5.1-6.7 min]) than in the ETI group (8.3 min [6.9-9.6 min]), as was time to overall successful placement at 6.0 min (5.1-6.8 min) versus 9.6 min (8.2-11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator-free days between the groups were not statistically different between the groups. Conclusion: In this natural experiment, the SGA performed significantly better than ETI in first-pass airway device placement success and was significantly faster in achieving first-pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.