The utility of β-blockers during an evolving ST-segment elevation myocardial infarction (STEMI) h... more The utility of β-blockers during an evolving ST-segment elevation myocardial infarction (STEMI) has substantial theoretic physiological backing. This coupled with early successes using β-blockers in STEMI promulgated multiple guidelines expanding the use of this class of medication to all patients with acute coronary syndromes. However, recent studies have questioned the utility of β-blockers in the emergency department in these patients. The purpose of this article is to review the evidence behind the use of β-blockers in the emergency department for STEMI patients.
Background: Increase in lactate (LAC) within the central nervous system after head trauma is an e... more Background: Increase in lactate (LAC) within the central nervous system after head trauma is an established marker of traumatic brain injury (TBI). Objective: To investigate the utility of arterial base deficit (BD) and LAC in identifying TBI in patients with isolated head injury (IHI). Materials and methods: TBI was defined as Glasgow Coma Scale (8, head Abbreviated Injury Severity Score .2 or brain haematoma on CT scan. Patients were divided into two groups: IHI with and without TBI. Data were reported as means (SDs). 131 patients with IHI were studied (mean (SD) age 39 (19) years, 78% male). Results: 17% of the patients sustained TBI. The mean differences for arterial BD (0.65 mmol/l, 95% CI 20.8 to 2.1) and LAC (0.34 mmol/l, 95% CI 20.7 to1.4) in patients with and without TBI were not significant. Analysis of receiver operating characteristic curves confirmed that arterial BD and LAC were unable to detect TBI in patients with IHI. Conclusion: Arterial BD and LAC are poor predictors of TBI in isolated head trauma.
The emergence of prothrombotic agents (e.g. activated factor VII) to treat traumatic brain injury... more The emergence of prothrombotic agents (e.g. activated factor VII) to treat traumatic brain injury (TBI) requires a better understanding of the association of coagulopathy with isolated head injury (IHI). To investigate the association of IHI and coagulopathy. Prospective, observational study in an urban level I trauma center. Adult (> or = 13 years of age) patients with IHI. patients with known coagulopathies or on anticoagulant therapy. TBI (head abbreviated injury severity score > 2, or brain hematoma on CT scan), age, gender, mechanism of injury, Glasgow Coma Score (GCS), and loss of consciousness (LOC). coagulopathy defined as elevated International Normalized Ratio (INR > 1.3) or activated partial thromboplastin time (PTT) greater than 34 s. We divided IHI subjects into two groups of patients with and without TBI. Fisher's exact test and Mann-Whitney U were used to compare data where appropriate (alpha: 0.05, two-tailed). From July 2005 to December 2006, 276 patients with IHI were studied. The median age was 35 years (interquartile range: 25-52) with a 79% male predominance and 88% blunt trauma. Eight percent (95% CI, 5-12%) of patients had coagulopathy. The rate of coagulopathy in TBI patients (17%) was significantly higher than non-TBI patients (6%) (11% difference, 95% CI, 3-20%]. The relative risk of coagulopathy in TBI patients was 2.9 (95% CI, 1.3-6.6). Coagulopathy as defined by elevated INR and/or PTT is associated with TBI after isolated head injury.
Journal of Stroke and Cerebrovascular Diseases, 2015
Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to rec... more Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods.
The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international at... more The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international attention. More information is needed on patient demographics, illness severity, and risk indicators. A total of 43 patients with H1N1 influenza A 2009 presenting to 2 urban academic medical centers during the first wave were assessed for demographics, triage vital signs, hemograms, and serum chemistries including lactate. Chest X-rays were assessed for infiltrate or effusion. Illness severity markers were recorded including anion gap (AG), strong ion gap (SIG), systemic inflammatory response syndrome score, shock index, confusion, uremia, respiratory rate, blood pressure, and age >= 65 years (CURB-65) score, and pneumonia severity index. Subgroup analysis was performed on asthmatic, pregnant, and intensive care unit (ICU) versus non-ICU patients. Eighty-one percent of patients were women. Pregnancy (34.8%), asthma (39.5%), diabetes mellitus (18.6%), and sickle cell (6.98%) were the mos...
The importance of early recognition of hemorrhagic shock and its effects on outcome have long bee... more The importance of early recognition of hemorrhagic shock and its effects on outcome have long been recognized. Traditional vital signs are relatively insensitive as early diagnostic markers of hemorrhage. The shock index (SI); heart rate (HR) divided by systolic blood pressure (SBP), has been suggested as such a marker. We tested the diagnostic utility of the SI in differentiating major from minor injury in trauma patients. Retrospective study of a prospectively collected observational cohort at a level I trauma center. Demographics, injury mechanism, HR, SBP, base deficit and lactate were recorded and Injury Severity Score were calculated. Major injury was defined as either a change in hematocrit greater than 10 or blood transfusion requirement during initial 24 h, or Injury Severity Score greater than 15. One thousand four hundred and thirty-five trauma patients were enrolled, average age 35.2±16.9 years. Two hundred and forty-two were classified as major injury. The area under th...
Contrast-induced acute kidney injury (CI-AKI) is defined as either a 25% increase in or an absolu... more Contrast-induced acute kidney injury (CI-AKI) is defined as either a 25% increase in or an absolute elevation in serum creatinine (SCr) of 0.5 mg/dL, 48 to 72 hours after parenteral contrast exposure. The objective of this study was to compare the incidence and complications of AKI between patients exposed and those unexposed to intravenous (IV) contrast. This was a retrospective cohort study using the electronic medical record of adult patients (>18 years) with and without contrast-enhanced abdominal or chest computed tomography (CT) between May 2008 and April 2009. Inclusion criteria were emergency department (ED) patients with normal renal function who received either a contrast-enhanced abdominal or a contrast-enhanced chest CT, compared to those unexposed to IV contrast, with a repeat SCr within 48 to 72 hours. Exclusion criteria were contrast exposure within 7 days before the index visit. CI-AKI in the contrast-exposed group and AKI in the contrast-unexposed group were defi...
Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in ... more Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population. We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957. Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17...
ferentiated emergency department (ED) patients are lacking. The objective of this study was to de... more ferentiated emergency department (ED) patients are lacking. The objective of this study was to determine the sensitivity of ESR and CRP in the diagnosis of SA. Methods: Retrospective analysis of ED patients diagnosed with of SA between January 2003 and December 2008. Eligible patients had an ICD-9 (International Classification of Diseases, 9 th Revision) diagnosis of pyogenic arthritis (711.0x) and one of the following: 1) positive synovial fluid culture; 2) positive synovial Gram stain for bacteria; or 3) operative irrigation for SA. Patients were excluded if no ESR or CRP were performed within 24 h of ED visit. Descriptive statistics and univariate analysis were performed. Sensitivity was calculated with 95% confidence interval (CI). The Partners Healthcare Human Research Committee approved the study. Results: We identified 143 patients with SA. The mean age was 49 (Ϯ 22) years, and 85 (59%) were male. Race was: 125 (87%) white, 4 (3%) black, and 12 (8%) Hispanic. Thirty-five (24%) had infection of prosthetic joints. Synovial cultures were positive in 102 (71%). ESR was done in 140 (98%), CRP in 96 (67%), and both tests in 93 (65%) patients. Sensitivity of ESR was: 97% (95% CI 92-99%) using a cutoff of Ͼ 10 mm/h, 86% (95% CI 79 -91%) using Ͼ 20 mm/h, and 78% (95% CI 70 -84%) using Ͼ 30 mm/h. Sensitivity of CRP was 92% (95% CI 84 -96%) using a cutoff of Ͼ 20 mg/L, 80% (95% CI 71-87%) using Ͼ 40 mg/L, and 73% (95% CI 63-81%) using Ͼ 60 mg/L. Using a combination of ESR and CRP, the sensitivity was: 99% (95% CI 94 -100%) using ESR Ͼ 10 mm/h or CRP Ͼ 20 mg/L; 96% (95% CI 90 -98%) using ESR Ͼ 20 mm/h or CRP Ͼ 40 mg/L; and 89% (95% CI 82-93%) using ESR Ͼ 30 mm/h or CRP Ͼ 60 mg/L. Conclusion: ESR and CRP are sensitive tests for SA, but only when very low cutoffs are used. At such low cutoffs, these tests are unlikely to have sufficient specificity to be clinically useful.
No consensus standard is established for the workup of diabetic patients with moderate hyperglyce... more No consensus standard is established for the workup of diabetic patients with moderate hyperglycemia [fingerstick glucose of 11.00-33.00 mmol/l (200-600 mg/dl)]. We measured the incidence of serious electrolyte abnormalities in patients with moderate hyperglycemia and attempted to identify a subset of these patients who can safely forego routine electrolyte testing. Prospective cohort study in two affiliated emergency departments. Inclusion criteria: Moderate hyperglycemia. Exclusion criteria: new onset diabetes or renal failure. The composite outcome was defined as an abnormal potassium K >5.00 or <3.50 mmol/l or diabetic ketoacidosis. Univariate analyses were performed using t-test and Fisher's exact test (alpha=0.05, two-tails). Logistic regression models were generated to identify variables that could predict the composite outcome. Three hundred and ninety-nine adults were enrolled (294 type II, 38% men). Mean age was 59+/-15 (20-97 years) years. The incidence of the c...
Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the d... more Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the diagnostic utility of decreasing haematocrit (DeltaHct) in detecting major injury. Additionally, we tested the correlation between the volume of infused intravenous fluid (IVF) and DeltaHct. Prospective observational study at a level one trauma centre. Inclusion criteria: Patients with suspected major injury. exclusion criteria: Patients who received blood transfusion in the first 4 h, and those who deceased or were transferred to other units before the completion of the observation period (4 h). We measured IVF and DeltaHct at 4 h after triage. We classified patients as having minor or major injury on the basis of injury severity score > or =15. Receiver Operating Characteristic (ROC) curve was used to test the diagnostic performance of DeltaHct in identifying major injury. We tested the operating characteristics of DeltaHct cut-off values of 5 and 10 in detecting major injury. We als...
Recent manmade and natural disasters have focused attention on the need to provide care to large ... more Recent manmade and natural disasters have focused attention on the need to provide care to large groups of patients. Clinicians, ethicists, and public health officials have been particularly concerned about mechanical ventilator surge capacity and have suggested stock-piling ventilators, rationing, and providing manual ventilation. These possible solutions are complex and variously limited by legal, monetary, physical, and human capital restraints. We conducted a study to determine if a single mechanical ventilator can adequately ventilate four adult-human-sized sheep for 12h. We utilized a four-limbed ventilator circuit connected in parallel. Four 70-kg sheep were intubated, sedated, administered neuromuscular blockade and placed on a single ventilator for 12h. The initial ventilator settings were: synchronized intermittent mandatory ventilation with 100% oxygen at 16 breaths/min and tidal volume of 6 ml/kg combined sheep weight. Arterial blood gas, heart rate, and mean arterial pressure measurements were obtained from all four sheep at time zero and at pre-determined times over the course of 12h. The ventilator and modified circuit successfully oxygenated and ventilated the four sheep for 12h. All sheep remained hemodynamically stable. It is possible to ventilate four adult-human-sized sheep on a single ventilator for at least 12h. This technique has the potential to improve disaster preparedness by expanding local ventilator surge capacity until emergency supplies can be delivered from central stockpiles. Further research should be conducted on ventilating individuals with different lung compliances and on potential microbial cross-contamination.
ABSTRACT Introduction: The identification of unmeasured plasma anions is an important biomarker f... more ABSTRACT Introduction: The identification of unmeasured plasma anions is an important biomarker for life-threatening metabolic derangements such as shock, ketosis, and toxins. Traditional measurements for calculating the anion gap (AG) are confounded by changes in pH, pCO2 and other cations and anions commonly altered in critically ill patients. The calculation of strong-ion gap (SIG) is a better marker for unmeasured anions than AG because it corrects for alterations in pH, PCO2, and other cations (calcium, magnesium) and anions (albumin, phosphorous) not included in the traditional AG calculation. Objective: To determine the prevalence of unmeasured anions by SIG in critically ill patients not identified by traditional measurements of lactate (LAC) and AG. Methods: Inclusion Criteria – Patients triaged or transferred to our emergency department’s critical care and trauma area because of impending respiratory or circulatory collapse. Exclusion Criteria: Patients dead-onarrival or died before obtaining blood work, or transferred from other institutions. Patients were divided into three groups: Group 1 (AG, LAC, and SIG all normal), Group 2 (AG and/or LAC elevated), GrouGroup 3 (AG and LAC normal and SIG elevated). Calculations: AG mEq/L = [Na+] – [Cl-] – [HCO3-]; SIG mEq/L = SIG(apparent) – SIG (effective); SIG mEq/L (apparent) = [Na+] + [K+] + [iCa++] + [iMg++] - [Cl-] – [LAC-]; SIG mEq/L (effective) = ((1000 x 2.46 x 10^-11 x PCO2 (mmHg)) / 10^-pH) + [Alb-] + [PO4–] Cutoffs: SIG &gt; 2.0 mEq/L (literature-based), and AG &gt; 15.0 mEq/L (hospital- norms) and lactate &gt; 2.2 mEq/L (hospital-norms). Data are reported as means +/)standard deviations or ratios with 95% confidence intervals (CIs). Results: Eighty patients were studied, mean age 55.8 yrs. +/)17.8 yrs, 62.5% male. Group I: n=13 16% (95% CI 10%–25%), Group 2: n=47 59% (95% CI 48%–69%), Group 3 n=20 25% (95% CI 17%–36%). Conclusions: SIG identified a significant percentage (25%) of critically ill patients with unmeasured anions missed by AG and LAC.
To identify and compare the operating characteristics of existing prehospital stroke scales to pr... more To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital. We searched MEDLINE, EMBASE, and CINAHL databases for articles that evaluated the performance of prehospital stroke scales. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We abstracted the operating characteristics of published prehospital stroke scales and compared them statistically and graphically. We retrieved 254 articles from MEDLINE, 66 articles from EMBASE, and 32 articles from CINAHL Plus database. Of these, 8 studies met all our inclusion criteria, and they studied Cincinnati Pre-Hospital Stroke Scale (CPSS), Los Angeles Pre-Hospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Te...
A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnan... more A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnant women is secondary to expanded blood volume. In addition to increased blood volume, pregnancy is also a vasodilated state. Vasodilatation may have deleterious effects on the response to hemorrhage by inhibiting central blood shunting after blood loss. How these conflicting variables of increased blood volume and vasodilatation integrate into a whole body model of maternal hemorrhagic shock has yet to be studied in a controlled experiment. We tested the null hypothesis that there would be no difference in the hemodynamic and metabolic responses to hemorrhage between pregnant (PRG) and non-pregnant (NPRG) rats. Twenty-four adult female Sprague-Dawley rats (12 PRG and 12 NPRG) were anesthetized with Althesin via the intraperitoneal route. Femoral arteries were cannulated by cut-down. Twelve (six PRG and six NPRG) rats underwent controlled catheter hemorrhage of 25% of their total blood volume. Twelve rats (six PRG and six NPRG) served as non-hemorrhage controls. Mean arterial pressure (MAP) and base excess (BE) were measured pre-hemorrhage and then every 15 min post-hemorrhage for the next 90 min. Data were reported as mean+/-standard error of the mean (S.E.M.) over the 90-min post-hemorrhage observation period. Group comparisons were analyzed by ANOVA with repeated values post-hoc by Bonferroni. Statistical significance was defined by an alpha=0.05. PRG and NPRG rats were evenly matched for MAP (P=0.788) and BE (P=0.146) pre-hemorrhage. Post-hemorrhage there were no mortalities in either group. Post-hemorrhage both the PRG and NPRG groups experienced significant (P=0.011) drops in systolic and diastolic blood pressures as compared to their non-hemorrhage controls. Post-hemorrhage there was no significant (P=0.43) difference in MAP between the PRG (89+/-2 mmHg) and NPRG (80+/-2 mmHg) rats. BE also dropped significantly within both PRG (P=0.004) and NPRG (P=0.001) groups post-hemorrhage. No significant (P=0.672) difference was noted in BE between PRG and NPRG groups post-hemorrhage -6.1+/-0.3 mEq/l and -6.9+/-0.4 mEq/l, respectively. After a controlled hemorrhage of 25% of total blood volume we found no significant differences in MAP and BE between pregnant and non-pregnant rats. Pregnancy does not affect the response to hemorrhage.
A traumatic insult initiates an inflammatory cascade, which is a contributor to cell damage and c... more A traumatic insult initiates an inflammatory cascade, which is a contributor to cell damage and could be a marker of injury severity. To compare the initial and 4-h post-injury lymphocyte subsets and cytokine levels between patients with minor and major injury. Prospective, cross-sectional study of trauma patients in an urban level I trauma center. Adult patients with significant mechanism of injury requiring admission. cell counts (B-cells, Natural Killer cells, monocytes; and CD4 and CD8 T lymphocytes) and cytokines (IL-1, IL-5, IL-6, IL-10, and TNFalpha). We divided subjects into two groups (major and minor injury). We defined major injury as an injury severity score > or =15, or drop in hematocrit > or =10 points or blood transfusion requirement. Univariate analysis was performed using each inflammatory marker, and multivariate logistic regression analysis was performed to identify the inflammatory markers associated with major injury. 79 patients were studied (mean age: 3...
The utility of β-blockers during an evolving ST-segment elevation myocardial infarction (STEMI) h... more The utility of β-blockers during an evolving ST-segment elevation myocardial infarction (STEMI) has substantial theoretic physiological backing. This coupled with early successes using β-blockers in STEMI promulgated multiple guidelines expanding the use of this class of medication to all patients with acute coronary syndromes. However, recent studies have questioned the utility of β-blockers in the emergency department in these patients. The purpose of this article is to review the evidence behind the use of β-blockers in the emergency department for STEMI patients.
Background: Increase in lactate (LAC) within the central nervous system after head trauma is an e... more Background: Increase in lactate (LAC) within the central nervous system after head trauma is an established marker of traumatic brain injury (TBI). Objective: To investigate the utility of arterial base deficit (BD) and LAC in identifying TBI in patients with isolated head injury (IHI). Materials and methods: TBI was defined as Glasgow Coma Scale (8, head Abbreviated Injury Severity Score .2 or brain haematoma on CT scan. Patients were divided into two groups: IHI with and without TBI. Data were reported as means (SDs). 131 patients with IHI were studied (mean (SD) age 39 (19) years, 78% male). Results: 17% of the patients sustained TBI. The mean differences for arterial BD (0.65 mmol/l, 95% CI 20.8 to 2.1) and LAC (0.34 mmol/l, 95% CI 20.7 to1.4) in patients with and without TBI were not significant. Analysis of receiver operating characteristic curves confirmed that arterial BD and LAC were unable to detect TBI in patients with IHI. Conclusion: Arterial BD and LAC are poor predictors of TBI in isolated head trauma.
The emergence of prothrombotic agents (e.g. activated factor VII) to treat traumatic brain injury... more The emergence of prothrombotic agents (e.g. activated factor VII) to treat traumatic brain injury (TBI) requires a better understanding of the association of coagulopathy with isolated head injury (IHI). To investigate the association of IHI and coagulopathy. Prospective, observational study in an urban level I trauma center. Adult (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 13 years of age) patients with IHI. patients with known coagulopathies or on anticoagulant therapy. TBI (head abbreviated injury severity score &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 2, or brain hematoma on CT scan), age, gender, mechanism of injury, Glasgow Coma Score (GCS), and loss of consciousness (LOC). coagulopathy defined as elevated International Normalized Ratio (INR &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 1.3) or activated partial thromboplastin time (PTT) greater than 34 s. We divided IHI subjects into two groups of patients with and without TBI. Fisher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s exact test and Mann-Whitney U were used to compare data where appropriate (alpha: 0.05, two-tailed). From July 2005 to December 2006, 276 patients with IHI were studied. The median age was 35 years (interquartile range: 25-52) with a 79% male predominance and 88% blunt trauma. Eight percent (95% CI, 5-12%) of patients had coagulopathy. The rate of coagulopathy in TBI patients (17%) was significantly higher than non-TBI patients (6%) (11% difference, 95% CI, 3-20%]. The relative risk of coagulopathy in TBI patients was 2.9 (95% CI, 1.3-6.6). Coagulopathy as defined by elevated INR and/or PTT is associated with TBI after isolated head injury.
Journal of Stroke and Cerebrovascular Diseases, 2015
Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to rec... more Stroke patients misdiagnosed by emergency medical services (EMS) providers have been shown to receive delayed in-hospital care. We aim at determining the diagnostic accuracy of Fire Department of New York (FDNY) EMS providers for stroke and identifying potential reasons for misdiagnosis. Prehospital care reports of all patients transported by FDNY EMS to 3 hospitals from January 1, 2010, to December 31, 2011, were compared against the American Heart Association Get With The Guidelines (GWTG) database (reference standard) for the diagnosis of stroke. Age-adjusted logistic regression models were generated to explore prehospital patient characteristics which are associated with stroke misdiagnosis. Of 72,984 patient transports during the study period, 750 had a GWTG diagnosis of stroke, 468 (62%) of which were identified correctly in the field and 282 (38%) were missed. An additional 268 patients were misdiagnosed as stroke when in fact they had an alternative diagnosis. Overall sensitivity was 62.4% (95% confidence interval [CI], 58.9-65.8) and specificity was 99.6% (95% CI, 99.6-99.7). No patients who presented with unilateral weakness, facial weakness, or speech problems were missed, whereas patients with atypical complaints like general malaise, dizziness, and headache were more likely to be missed. Seizures led the EMS providers to both overcall a stroke and miss the diagnosis. FDNY EMS care providers missed more than a third of stroke cases. Seizures and other atypical presentations contribute significantly to stroke misdiagnosis in the field. Our findings highlight the need for better prehospital stroke identification methods.
The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international at... more The influenza A 2009 (H1N1) virus is a pandemic respiratory infection commanding international attention. More information is needed on patient demographics, illness severity, and risk indicators. A total of 43 patients with H1N1 influenza A 2009 presenting to 2 urban academic medical centers during the first wave were assessed for demographics, triage vital signs, hemograms, and serum chemistries including lactate. Chest X-rays were assessed for infiltrate or effusion. Illness severity markers were recorded including anion gap (AG), strong ion gap (SIG), systemic inflammatory response syndrome score, shock index, confusion, uremia, respiratory rate, blood pressure, and age >= 65 years (CURB-65) score, and pneumonia severity index. Subgroup analysis was performed on asthmatic, pregnant, and intensive care unit (ICU) versus non-ICU patients. Eighty-one percent of patients were women. Pregnancy (34.8%), asthma (39.5%), diabetes mellitus (18.6%), and sickle cell (6.98%) were the mos...
The importance of early recognition of hemorrhagic shock and its effects on outcome have long bee... more The importance of early recognition of hemorrhagic shock and its effects on outcome have long been recognized. Traditional vital signs are relatively insensitive as early diagnostic markers of hemorrhage. The shock index (SI); heart rate (HR) divided by systolic blood pressure (SBP), has been suggested as such a marker. We tested the diagnostic utility of the SI in differentiating major from minor injury in trauma patients. Retrospective study of a prospectively collected observational cohort at a level I trauma center. Demographics, injury mechanism, HR, SBP, base deficit and lactate were recorded and Injury Severity Score were calculated. Major injury was defined as either a change in hematocrit greater than 10 or blood transfusion requirement during initial 24 h, or Injury Severity Score greater than 15. One thousand four hundred and thirty-five trauma patients were enrolled, average age 35.2±16.9 years. Two hundred and forty-two were classified as major injury. The area under th...
Contrast-induced acute kidney injury (CI-AKI) is defined as either a 25% increase in or an absolu... more Contrast-induced acute kidney injury (CI-AKI) is defined as either a 25% increase in or an absolute elevation in serum creatinine (SCr) of 0.5 mg/dL, 48 to 72 hours after parenteral contrast exposure. The objective of this study was to compare the incidence and complications of AKI between patients exposed and those unexposed to intravenous (IV) contrast. This was a retrospective cohort study using the electronic medical record of adult patients (>18 years) with and without contrast-enhanced abdominal or chest computed tomography (CT) between May 2008 and April 2009. Inclusion criteria were emergency department (ED) patients with normal renal function who received either a contrast-enhanced abdominal or a contrast-enhanced chest CT, compared to those unexposed to IV contrast, with a repeat SCr within 48 to 72 hours. Exclusion criteria were contrast exposure within 7 days before the index visit. CI-AKI in the contrast-exposed group and AKI in the contrast-unexposed group were defi...
Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in ... more Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population. We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957. Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17...
ferentiated emergency department (ED) patients are lacking. The objective of this study was to de... more ferentiated emergency department (ED) patients are lacking. The objective of this study was to determine the sensitivity of ESR and CRP in the diagnosis of SA. Methods: Retrospective analysis of ED patients diagnosed with of SA between January 2003 and December 2008. Eligible patients had an ICD-9 (International Classification of Diseases, 9 th Revision) diagnosis of pyogenic arthritis (711.0x) and one of the following: 1) positive synovial fluid culture; 2) positive synovial Gram stain for bacteria; or 3) operative irrigation for SA. Patients were excluded if no ESR or CRP were performed within 24 h of ED visit. Descriptive statistics and univariate analysis were performed. Sensitivity was calculated with 95% confidence interval (CI). The Partners Healthcare Human Research Committee approved the study. Results: We identified 143 patients with SA. The mean age was 49 (Ϯ 22) years, and 85 (59%) were male. Race was: 125 (87%) white, 4 (3%) black, and 12 (8%) Hispanic. Thirty-five (24%) had infection of prosthetic joints. Synovial cultures were positive in 102 (71%). ESR was done in 140 (98%), CRP in 96 (67%), and both tests in 93 (65%) patients. Sensitivity of ESR was: 97% (95% CI 92-99%) using a cutoff of Ͼ 10 mm/h, 86% (95% CI 79 -91%) using Ͼ 20 mm/h, and 78% (95% CI 70 -84%) using Ͼ 30 mm/h. Sensitivity of CRP was 92% (95% CI 84 -96%) using a cutoff of Ͼ 20 mg/L, 80% (95% CI 71-87%) using Ͼ 40 mg/L, and 73% (95% CI 63-81%) using Ͼ 60 mg/L. Using a combination of ESR and CRP, the sensitivity was: 99% (95% CI 94 -100%) using ESR Ͼ 10 mm/h or CRP Ͼ 20 mg/L; 96% (95% CI 90 -98%) using ESR Ͼ 20 mm/h or CRP Ͼ 40 mg/L; and 89% (95% CI 82-93%) using ESR Ͼ 30 mm/h or CRP Ͼ 60 mg/L. Conclusion: ESR and CRP are sensitive tests for SA, but only when very low cutoffs are used. At such low cutoffs, these tests are unlikely to have sufficient specificity to be clinically useful.
No consensus standard is established for the workup of diabetic patients with moderate hyperglyce... more No consensus standard is established for the workup of diabetic patients with moderate hyperglycemia [fingerstick glucose of 11.00-33.00 mmol/l (200-600 mg/dl)]. We measured the incidence of serious electrolyte abnormalities in patients with moderate hyperglycemia and attempted to identify a subset of these patients who can safely forego routine electrolyte testing. Prospective cohort study in two affiliated emergency departments. Inclusion criteria: Moderate hyperglycemia. Exclusion criteria: new onset diabetes or renal failure. The composite outcome was defined as an abnormal potassium K >5.00 or <3.50 mmol/l or diabetic ketoacidosis. Univariate analyses were performed using t-test and Fisher's exact test (alpha=0.05, two-tails). Logistic regression models were generated to identify variables that could predict the composite outcome. Three hundred and ninety-nine adults were enrolled (294 type II, 38% men). Mean age was 59+/-15 (20-97 years) years. The incidence of the c...
Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the d... more Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the diagnostic utility of decreasing haematocrit (DeltaHct) in detecting major injury. Additionally, we tested the correlation between the volume of infused intravenous fluid (IVF) and DeltaHct. Prospective observational study at a level one trauma centre. Inclusion criteria: Patients with suspected major injury. exclusion criteria: Patients who received blood transfusion in the first 4 h, and those who deceased or were transferred to other units before the completion of the observation period (4 h). We measured IVF and DeltaHct at 4 h after triage. We classified patients as having minor or major injury on the basis of injury severity score > or =15. Receiver Operating Characteristic (ROC) curve was used to test the diagnostic performance of DeltaHct in identifying major injury. We tested the operating characteristics of DeltaHct cut-off values of 5 and 10 in detecting major injury. We als...
Recent manmade and natural disasters have focused attention on the need to provide care to large ... more Recent manmade and natural disasters have focused attention on the need to provide care to large groups of patients. Clinicians, ethicists, and public health officials have been particularly concerned about mechanical ventilator surge capacity and have suggested stock-piling ventilators, rationing, and providing manual ventilation. These possible solutions are complex and variously limited by legal, monetary, physical, and human capital restraints. We conducted a study to determine if a single mechanical ventilator can adequately ventilate four adult-human-sized sheep for 12h. We utilized a four-limbed ventilator circuit connected in parallel. Four 70-kg sheep were intubated, sedated, administered neuromuscular blockade and placed on a single ventilator for 12h. The initial ventilator settings were: synchronized intermittent mandatory ventilation with 100% oxygen at 16 breaths/min and tidal volume of 6 ml/kg combined sheep weight. Arterial blood gas, heart rate, and mean arterial pressure measurements were obtained from all four sheep at time zero and at pre-determined times over the course of 12h. The ventilator and modified circuit successfully oxygenated and ventilated the four sheep for 12h. All sheep remained hemodynamically stable. It is possible to ventilate four adult-human-sized sheep on a single ventilator for at least 12h. This technique has the potential to improve disaster preparedness by expanding local ventilator surge capacity until emergency supplies can be delivered from central stockpiles. Further research should be conducted on ventilating individuals with different lung compliances and on potential microbial cross-contamination.
ABSTRACT Introduction: The identification of unmeasured plasma anions is an important biomarker f... more ABSTRACT Introduction: The identification of unmeasured plasma anions is an important biomarker for life-threatening metabolic derangements such as shock, ketosis, and toxins. Traditional measurements for calculating the anion gap (AG) are confounded by changes in pH, pCO2 and other cations and anions commonly altered in critically ill patients. The calculation of strong-ion gap (SIG) is a better marker for unmeasured anions than AG because it corrects for alterations in pH, PCO2, and other cations (calcium, magnesium) and anions (albumin, phosphorous) not included in the traditional AG calculation. Objective: To determine the prevalence of unmeasured anions by SIG in critically ill patients not identified by traditional measurements of lactate (LAC) and AG. Methods: Inclusion Criteria – Patients triaged or transferred to our emergency department’s critical care and trauma area because of impending respiratory or circulatory collapse. Exclusion Criteria: Patients dead-onarrival or died before obtaining blood work, or transferred from other institutions. Patients were divided into three groups: Group 1 (AG, LAC, and SIG all normal), Group 2 (AG and/or LAC elevated), GrouGroup 3 (AG and LAC normal and SIG elevated). Calculations: AG mEq/L = [Na+] – [Cl-] – [HCO3-]; SIG mEq/L = SIG(apparent) – SIG (effective); SIG mEq/L (apparent) = [Na+] + [K+] + [iCa++] + [iMg++] - [Cl-] – [LAC-]; SIG mEq/L (effective) = ((1000 x 2.46 x 10^-11 x PCO2 (mmHg)) / 10^-pH) + [Alb-] + [PO4–] Cutoffs: SIG &gt; 2.0 mEq/L (literature-based), and AG &gt; 15.0 mEq/L (hospital- norms) and lactate &gt; 2.2 mEq/L (hospital-norms). Data are reported as means +/)standard deviations or ratios with 95% confidence intervals (CIs). Results: Eighty patients were studied, mean age 55.8 yrs. +/)17.8 yrs, 62.5% male. Group I: n=13 16% (95% CI 10%–25%), Group 2: n=47 59% (95% CI 48%–69%), Group 3 n=20 25% (95% CI 17%–36%). Conclusions: SIG identified a significant percentage (25%) of critically ill patients with unmeasured anions missed by AG and LAC.
To identify and compare the operating characteristics of existing prehospital stroke scales to pr... more To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital. We searched MEDLINE, EMBASE, and CINAHL databases for articles that evaluated the performance of prehospital stroke scales. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We abstracted the operating characteristics of published prehospital stroke scales and compared them statistically and graphically. We retrieved 254 articles from MEDLINE, 66 articles from EMBASE, and 32 articles from CINAHL Plus database. Of these, 8 studies met all our inclusion criteria, and they studied Cincinnati Pre-Hospital Stroke Scale (CPSS), Los Angeles Pre-Hospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Te...
A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnan... more A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnant women is secondary to expanded blood volume. In addition to increased blood volume, pregnancy is also a vasodilated state. Vasodilatation may have deleterious effects on the response to hemorrhage by inhibiting central blood shunting after blood loss. How these conflicting variables of increased blood volume and vasodilatation integrate into a whole body model of maternal hemorrhagic shock has yet to be studied in a controlled experiment. We tested the null hypothesis that there would be no difference in the hemodynamic and metabolic responses to hemorrhage between pregnant (PRG) and non-pregnant (NPRG) rats. Twenty-four adult female Sprague-Dawley rats (12 PRG and 12 NPRG) were anesthetized with Althesin via the intraperitoneal route. Femoral arteries were cannulated by cut-down. Twelve (six PRG and six NPRG) rats underwent controlled catheter hemorrhage of 25% of their total blood volume. Twelve rats (six PRG and six NPRG) served as non-hemorrhage controls. Mean arterial pressure (MAP) and base excess (BE) were measured pre-hemorrhage and then every 15 min post-hemorrhage for the next 90 min. Data were reported as mean+/-standard error of the mean (S.E.M.) over the 90-min post-hemorrhage observation period. Group comparisons were analyzed by ANOVA with repeated values post-hoc by Bonferroni. Statistical significance was defined by an alpha=0.05. PRG and NPRG rats were evenly matched for MAP (P=0.788) and BE (P=0.146) pre-hemorrhage. Post-hemorrhage there were no mortalities in either group. Post-hemorrhage both the PRG and NPRG groups experienced significant (P=0.011) drops in systolic and diastolic blood pressures as compared to their non-hemorrhage controls. Post-hemorrhage there was no significant (P=0.43) difference in MAP between the PRG (89+/-2 mmHg) and NPRG (80+/-2 mmHg) rats. BE also dropped significantly within both PRG (P=0.004) and NPRG (P=0.001) groups post-hemorrhage. No significant (P=0.672) difference was noted in BE between PRG and NPRG groups post-hemorrhage -6.1+/-0.3 mEq/l and -6.9+/-0.4 mEq/l, respectively. After a controlled hemorrhage of 25% of total blood volume we found no significant differences in MAP and BE between pregnant and non-pregnant rats. Pregnancy does not affect the response to hemorrhage.
A traumatic insult initiates an inflammatory cascade, which is a contributor to cell damage and c... more A traumatic insult initiates an inflammatory cascade, which is a contributor to cell damage and could be a marker of injury severity. To compare the initial and 4-h post-injury lymphocyte subsets and cytokine levels between patients with minor and major injury. Prospective, cross-sectional study of trauma patients in an urban level I trauma center. Adult patients with significant mechanism of injury requiring admission. cell counts (B-cells, Natural Killer cells, monocytes; and CD4 and CD8 T lymphocytes) and cytokines (IL-1, IL-5, IL-6, IL-10, and TNFalpha). We divided subjects into two groups (major and minor injury). We defined major injury as an injury severity score > or =15, or drop in hematocrit > or =10 points or blood transfusion requirement. Univariate analysis was performed using each inflammatory marker, and multivariate logistic regression analysis was performed to identify the inflammatory markers associated with major injury. 79 patients were studied (mean age: 3...
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Papers by Richard Sinert