The significance of non-sustained hypotension in emergency department patients with sepsis

Objective  Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis. Methods  Secondary analysis of a prospective cohort study. ED patients aged >17 years admitted to the hospital with explicitly defined sepsis were prospectively identified. Inclusion criteria  Evidence of systemic inflammation (>1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality. Results  Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5–5.2). Patients with a lowest systolic blood pressure <80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure ≥80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality. Conclusion  Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Secondary insults in severe head injury--do multiply injured patients do worse?

OBJECTIVES: To study the occurrence of secondary insults and the influence of extracranial injuries on cerebral oxygenation and outcome in patients with closed severe head injury (Glasgow Coma Scale score < or =8). DESIGN: Two-year prospective, clinical study. SETTING: Two intensive care units in a level III trauma center. PATIENTS: We studied 119 patients. Eighty patients had severe head injury and were divided into two categories: "isolated" severe head injury patients (n = 36, Injury Severity Score <30), and severe head injury patients with associated extracranial injuries (n = 44, Injury Severity Score >29). Thirty-nine patients with extracranial injuries and no head injury served as the control group. INTERVENTIONS: After patients were admitted to the intensive care unit, we began continuous multimodal cerebral monitoring of intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure, end-tidal Co2, brain tissue Po2 (Licox), jugular bulb oxyhemoglobin saturation in severe head injury patients, and mean arterial blood pressure in the control group. Targets of management included intracranial pressure <20 mm Hg, cerebral perfusion pressure >60 mm Hg, Paco2 > 30 mm Hg, control of cerebral oxygenation, and delayed surgery for non-life-threatening extracranial lesions. MEASUREMENTS AND MAIN RESULTS: Data were analyzed for critical thresholds. The occurrence of secondary insults (intracranial pressure >20 mm Hg, mean arterial blood pressure <70 mm Hg, cerebral perfusion pressure <60 mm Hg, end-tidal Co2 <30 torr, brain tissue Po2 <10 torr, jugular bulb oxyhemoglobin saturation <50%) was comparable in patients with isolated severe head injury and those with severe head injury with associated extracranial lesions (Abbreviated Injury Scale score < or =5). The duration of intracranial hypertension and arterial hypotension significantly correlated with an unfavorable outcome, independent of the Injury Severity Score. In patients with severe head injury, 1-yr outcome was 29% dead or vegetative, 17% severely disabled, and 54% moderate or good outcome. This was similar to patients with severe head injury and extracranial injuries (31% dead or vegetative, 14% severely disabled, and 56% moderate or good outcome) and was independent of the Injury Severity Score. Patients with no head injury had less secondary insults (mean arterial blood pressure <70 mm Hg, p <.01) and a better outcome compared with both severe head injury groups (p <.044). CONCLUSIONS: In patients with severe head injury who have targeted management including intracranial pressure- and cerebral perfusion pressure-guided therapy and delayed surgery for extracranial lesions, the occurrence of secondary insults in the intensive care unit and long-term neurological outcome were comparable and independent of the presence of extracranial lesions (Abbreviated Injury Severity level < or =5). A severe head injury is still a major contributor predicting an unfavorable outcome in multiply injured patients.     

Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma

Background: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field. Methods: Adult severe trauma (ST) patients during 2012–13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders. Results: A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92–2.40) for mortality and was 1.97 (1.75–2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32–3.04) and 1.74 (1.61–1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87–2.53) and 1.55 (1.42–1.69), respectively (P < 0.0001 for interaction). Conclusions: The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability.     

Outcome after severe head injury treated by an integrated trauma system.

OBJECTIVES: To describe outcome after treatment of severe head injury within an integrated trauma system. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) between 1991 and 1994. Type of injury was defined on initial computed tomography of the head and outcomes assessed 12 months after injury using the Glasgow outcome score. RESULTS: 6.5% of HEMS patients had long term severe disability (severe disability or persistent vegetative state on the outcome score); 34.5% made a good recovery. CONCLUSIONS: The concern that a large number of severely disabled long term survivors might result as a consequence of this system of trauma management is not confirmed. The case mix of severity of extracranial injuries in these patients makes comparison with other published series difficult, but these data fit the hypothesis that pre-hospital correction of hypoxia and hypotension after head injury improves outcome.     

Outcome after severe head injury treated by an integrated trauma system.

OBJECTIVES: To describe outcome after treatment of severe head injury within an integrated trauma system. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) between 1991 and 1994. Type of injury was defined on initial computed tomography of the head and outcomes assessed 12 months after injury using the Glasgow outcome score. RESULTS: 6.5% of HEMS patients had long term severe disability (severe disability or persistent vegetative state on the outcome score); 34.5% made a good recovery. CONCLUSIONS: The concern that a large number of severely disabled long term survivors might result as a consequence of this system of trauma management is not confirmed. The case mix of severity of extracranial injuries in these patients makes comparison with other published series difficult, but these data fit the hypothesis that pre-hospital correction of hypoxia and hypotension after head injury improves outcome.     

Evaluation of geriatric patients with trauma scores after motor vehicle trauma

IntroductionThe aim of this study was to investigate the factors affecting in-hospital mortality among geriatric trauma patients who presented to the emergency department (ED) following a motor vehicle collision.MethodsA retrospective cohort study was carried out in a high-volume tertiary care facility in the central Anatolian Region. Clinical data were extracted from hospital databases for all eligible geriatric patients (either driver, passenger or pedestrian) with entries dated between January 1, 2007, and December 31, 2009. Multivariate logistic regression analysis was used to assess the in-hospital mortality effects of variables including demographic characteristics, trauma mechanisms, injured body parts and various trauma scores.ResultsThere were 395 geriatric motor vehicle trauma presentations to the ED during the 3-year period. Of these patients, 371 (93.9%) survived, and 24 (6.1%) died in the ED, operating room or intensive care unit. The multivariate logistic regression model included the following variables: heart failure, cranial trauma, abdominal trauma, thoracic trauma, pelvic trauma, Glasgow Coma Score and Injury Severity Score (ISS). These variables were chosen because univariate analysis indicated that they were potential predictors of mortality. The multivariate logistic regression showed that the presence of heart failure (OR: 20.2), cranial trauma (OR: 3.6), abdominal trauma (OR: 26.9), pelvic trauma (OR: 9.9) and ISS (OR: 1.2) were predictors of in-hospital mortality in the study population.ConclusionIn our study, heart failure, cranial trauma, abdominal trauma, pelvic trauma, and ISS were found to be the most important predictors of in-hospital mortality among geriatric motor vehicle trauma patients.     

Isolated prehospital hypotension after traumatic injuries: a predictor of mortality?

In patients with traumatic injuries, prehospital hypotension that resolves by Emergency Department (ED) arrival is of uncertain significance. We examined the impact of prehospital hypotension (PH) in normotensive ED patients with traumatic injuries on predicting mortality and chest/abdominal operative intervention. A retrospective cohort study was conducted of consecutive patients undergoing helicopter transport to two trauma centers between 1993 and 1997. Outcomes were mortality and chest or abdominal operative intervention. Of 545 scene transports, 55 (10.1%) patients were hypotensive on ED arrival, leaving 490 normotensive ED patients. Of 490 patients, 35 (7%) had PH and 455 (93%) had no PH. Multiple logistic regression showed the PH group to have a relative risk for death of 4.4 (95% CI: 1.2-16.6, p < 0.03) and for chest or abdominal operative intervention of 2.9 (1.1-7.6, p < 0.03). In this study of normotensive trauma center patients, prehospital hypotension was associated with increased risk of mortality and significant chest or abdominal injury.     

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study

Background

Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L).

T HE U SE OF E TOMIDATE FOR P REHOSPITAL R APID-SEQUENCE I NTUBATION

Prehospital hypoxia and hypotension increase morbidity and mortality in head-injured patients. Etomidate is a sedative agent with increasing use for emergent rapid-sequence intubation (RSI) because of its favorable hemodynamic profile. This prospective, observational study documents the authors' preliminary experience with etomidate as part of an aeromedical RSI protocol. Major trauma victims received etomidate 0.1 to 0.3?mg/kg intravenously (IV) before administration of a neuromuscular-blocking agent. After confirmation of endotracheal tube position, 1 to 2?mg midazolam IV was administered. The main outcome measure was systolic blood pressure (SBP) before and after the RSI procedure and the incidence of hypotension after RSI; individual patient plots of SBP versus time were also included for graphic analysis. An improvement in SBP after RSI with etomidate was observed (123?mm Hg to 136?mm Hg, p = 0.011) with a 9% incidence of hypotension, defined as a decrease in SBP to 90?mm Hg or less. Graphic analysis of individual SBP-time plots reveals hemodynamic stability, especially in patients with lower initial SBP values. These data suggest that the use of etomidate as part of a prehospital RSI protocol is associated with hemodynamic stability and a low incidence of hypotension.     

The Significance of Out-of-hospital Hypotension in Blunt Trauma Patients

Objective: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.
Methods: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.
Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).
Conclusion: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.     

Significant factors in predicting sustained ROSC in paediatric patients with traumatic out-of-hospital cardiac arrest admitted to the emergency department

BACKGROUND: Paediatric patients with out-of-hospital cardiac arrest (OHCA) due to trauma pose difficult challenges in resuscitation. Trauma is a major cause of OHCA in children. The aim of this study was to determine which factors were related to predicting a sustained return of spontaneous circulation (ROSC) in paediatric OHCA patients with trauma. METHOD: This retrospective study comprised 115 paediatric patients (56 traumatic and 59 non-traumatic OHCA patients) aged younger than 18 years who had been admitted to the emergency department (ED) from January 2000 to December 2004. We analysed the demographic data and the factors that may have influenced sustained ROSC in the group of OHCA paediatric patients with trauma. The non-trauma group was established as a control group. Survival analysis was used to compare differences in survival rate between trauma and non-trauma OHCA patients. Receiver operating characteristic (ROC) analysis was used to determine the significant in-hospital CPR duration related to sustained ROSC. RESULTS: Initial cardiac rhythm on arrival (P=0.005) and the duration of in-hospital CPR (P<0.001) were significant factors. Patients with PEA or VF had higher rate of sustained ROSC than those with asystole (PEA: P=0.003, VF: P=0.03). In the survival analysis, OHCA children with trauma had a lower chance of survival than non-trauma children as the interval from the scene to the ER increased (P=0.008). Based on the ROC analysis, the cut-off values of in-hospital CPR duration were 25min in OHCA paediatric patients with trauma. CONCLUSION: Several significant factors relating to sustained ROSC were determined in the OHCA paediatric patients with trauma; most importantly, we found that in-hospital CPR may have to be performed for at least 25min to enable a spontaneous circulation to return.     

A Retrospective Review of the Use and Safety of Droperidol in a Large, High-risk, Inner-city Emergency Department Patient Population

Droperidol (DROP) is used in the emergency department (ED) for sedation, analgesia, and its antiemetic effect. Its ED safety profile has not yet been reported in patients (pts). OBJECTIVES: To document the use of DROP in high-risk pts (those with head injury, alcohol or cocaine intoxication, and/or remote or recent seizures), and to determine the number of serious and minor adverse events (AEs)-seizures, hypotension, extrapyramidal side effects (EPSEs)-after DROP. METHODS: The ED database (EmSTAT) was queried to determine who received intramuscular or intravenous DROP in the ED in 1998; further chart review was done if the patient was considered high risk for or had experienced an AE. Multiple regression analysis using a random-effects model determined the significance of each variable in the occurrence of AEs. RESULTS: 2,468 patients (aged 20 months to 98 years; 112 < or =17 years; 141 > or =66 years) received DROP for agitation (n = 1,357), pain (1,135), anxiety (99), vomiting (173), or other reasons (50). There were 945 pts considered high risk; 933 charts were reviewed (DROP mean dose 4.1 +/- 2.0 mg); of these, 50 patient visits did not meet the criteria for high risk. There were 622 pts with head trauma (401 with alcohol use), including 47 with computed tomography (CT) scans positive for brain injury, 64 with cocaine use, and 197 with recent or remote seizures (137 with alcohol use). Minor AEs such as transient hypotension occurred in 96 pts after DROP (73 with alcohol use); 20 received intravenous fluids, while an additional 28 pts (8 with alcohol use) received rescue medications for EPSEs. Six possible serious AEs occurred in pts with serious comorbidities; 2 cases of respiratory depression, 3 post-DROP seizures, and 1 cardiac arrest (resuscitated) 11 hours after DROP in a cocaine-intoxicated pt (normal QT interval). There was no significant difference among high-risk groups in the occurrence of AEs. CONCLUSIONS: The vast majority of pts who received DROP in the ED did not experience an AE. A few serious AEs were noted following DROP in patients with serious comorbidities; it is not clear that DROP was causative.     

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?

BackgroundPrehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.ObjectivesIn this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.MethodsThe study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.ResultsA total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.ConclusionsPrehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.     

Emergency Department Control of Blood Pressure in Intracerebral Hemorrhage

Background: Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. Study Objective: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED). Methods: A single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100–110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. Results: A total of 22 patients were enrolled over a 1-year study period. The average time to achieve our target MAP after implementation of our protocol was 123 min (range 19–297 min). The average time to arterial line placement was 84 min (range 36–160 min). Overall, 77% of the patients tolerated the 24-h protocol. The in-hospital mortality rate in this group of patients was 41%. Conclusions: Adopting a protocol to reduce and maintain the MAP to a target of 100–110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.     

Early diagnosis and survival of ruptured abdominal aortic aneurysms

The hospital records of patients treated with ruptured abdominal aortic aneurysm in a recent 5-year period were reviewed to collect data on factors which may be associated with mortality. Overall mortality was 62%. Patients with intraperitoneal rupture had a higher mortality (97%) than patients with retroperitoneal rupture (25%). Patients at increased risk were older than 80 years, presented with syncope, experienced a short duration of symptoms prior to emergency department (ED) arrival, had initial systolic blood pressure less than 90 mm Hg, and/or initial hemoglobin level less than eight on arrival at the ED and delay in beginning surgery. Multivariate analysis demonstrated preoperative blood pressure, preoperative hemoglobin, presence of syncope, and the amount of blood transfused were largely reflections of the type of rupture and had only slight independent relationship to mortality. The authors concluded that treating emergency physicians and surgeons have little control over the most important risk factors for mortality after aneurysm rupture, but may improve the prognosis by expediting diagnosis in the ED and surgical therapy.     

Factors Affecting Emergency Department Opioid Administration to Severely Injured Patients

OBJECTIVES: Studies of emergency department (ED) pain management in patients with trauma have been mostly restricted to patients with fractures, yet the potential for undertreatment of more severely injured patients is great. The authors sought to identify factors associated with failure to receive ED opioid administration in patients with acute trauma who subsequently required hospitalization. METHODS: At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study of trauma team activation patients requiring hospitalization between January 1 and December 31, 1999, was conducted. The authors excluded patients receiving opioids only within ten minutes of chest tube insertion or fracture manipulation. The main outcome measure was ED opioid administration. RESULTS: A total of 540 charts of hospitalized first-tier trauma team activation patients were reviewed. A total of 258 (47.8%) received intravenous opioid analgesia within three hours of ED arrival. The median time to receiving the first dose of opioids was 95 minutes. Patients were independently less likely to receive opioids if they were younger or older, were intubated, had a lower Revised Trauma Score, or did not require fracture manipulation. Patients with these factors were less likely to receive opioids independent of the amount of time they spent in the ED. CONCLUSIONS: Many trauma activation patients requiring hospitalization do not receive opioid analgesia in the ED. Patients at particular risk for oligoanalgesia include those who are younger or older and those who are more seriously injured, as defined by a lower Revised Trauma Score, lower Glasgow Coma Scale score, and intubation.     

Emergency Department Presentation of Patients with Conversion Disorder

Objective: To describe the presenting symptoms and other features of ED patients diagnosed as having conversion disorder.
Methods: A retrospective chart review was carried out on the records of ED patients who had had final ED or in-hospital diagnoses of conversion disorder. Cases from 1982 to 1992 at a 566-bed rural tertiary care hospital with a residency program in emergency medicine were reviewed for patient age and gender, presenting signs and symptoms, ED diagnostic evaluation, disposition, and comorbidity.
Results: Of 42 patients who had conversion disorder diagnoses, 24 were women and 18 were men. Twenty-one (50%) of the patients were diagnosed in the ED, and of those patients, ten were released home from the ED. Patient age ranged from 5 to 70 years, with a mean age of 33 years for women and 34 years for men. Most clinical symptoms mimicked neurologic disorders (weakness, pain, seizurelike activity, loss of consciousness, etc). Thirty patients (71%) received laboratory studies in the ED and two others received laboratory studies on admission. Seventeen (40%) patients had computed tomography of the head and five (12%) patients had magnetic resonance imaging of the head. Twelve (29%) patients had previous histories of psychiatric disorders, four (10%) had histories of alcohol and drug abuse, two (5%) had prior conversion reactions, three (7%) had chronic illnesses, and four (10%) had been victims of previous head trauma.
Conclusion: Patients with conversion disorder in the ED usually present with neurologic symptoms and undergo multiple diagnostic tests. Comorbidity is common. Early psychiatric evaluation may assist in the diagnosis and evaluation of patients with suspected conversion disorder in the ED.     

Evaluation and Management of Moderate to Severe Pediatric Head Trauma

A case of pediatric head trauma is presented with a detailed discussion of current concepts in evaluation and treatment. Management of the moderate to severe head-injured child is reviewed, and best practices for emergency department treatment are discussed. Background: Pediatric head trauma is a common and potentially devastating injury. Thorough knowledge of the clinical evaluation and treatment will assist the emergency physician in providing optimal care. Discussion: Using a case-based scenario, the initial management strategies along with rationale evidence-based treatments are reviewed. Conclusions: Computed tomography scan is the diagnostic test of choice for the moderate to severe head-injured pediatric patient. Several unique scales to describe and prognosticate the head injury are discussed, although currently, the Glasgow Coma Scale is still the most commonly accepted one. Similar to the adult patient, avoidance of hypotension and hypoxia are key to decreasing mortality. Etomidate and succinylcholine remain the choice of medications for intubation. Hyperventilation should be avoided.     

Early predictors of sepsis in the motor-vehicle crash trauma victim

INTRODUCTION: Sepsis is a major cause of late morbidity and mortality in the victim of trauma. Currently, there is no method that is clinically practical and accurate for predicting the occurrence of sepsis in trauma victims. METHODS: Data were collected on 3,759 motor-vehicle crash victims from 16 hospitals during a 4 1/2 year period. Retrospective analysis was done to examine the relationship of patient and injury factors known within the first 24 hours of admission on the development of sepsis. RESULTS: Sepsis developed in 154 patients (4.1%) who had a mortality rate of 17.5%. Significant early predictors of sepsis included: 1) certain pre-existing conditions; 2) blood transfusion required; 3) seven or more injuries; 4) Glasgow Coma Scale score <10 and hypotension [corrected]; 5) major blood vessel injury; 6) head trauma; 7) internal injury of the chest or abdomen; 8) spinal-cord injury; and 9) certain fracture types. CONCLUSIONS: These predictors might help target high-risk patients and, thus, promote earlier and more effective treatment for those patients.     

Prevalence of orthostatic hypotension among patients presenting with syncope in the ED

We sought to determine the prevalence of orthostatic hypotension as a cause of syncope in the emergency setting, and describe the characteristics of patients diagnosed with this condition. Blood pressure orthostatic changes were measured prospectively in a standardized fashion up to 10 minutes, or until symptoms occurred, in all consecutive patients with syncope as a chief complaint presenting in the emergency department (ED) of a primary and tertiary care hospital. Patients unable to stand-up were excluded. Hypotension was considered to be the cause of syncope when there was: (1) a decrease in systolic blood pressure (SBP) >or= 20 mm Hg with simultaneous symptoms; (2) a decrease in SBP between 10 and 20 mm Hg, but a SBP or= 20 mm Hg were found in 10% of patients with syncope attributed to other causes. Compared with patients with vasovagal disorder, those with orthostatic hypotension were older; had more comorbid conditions including hypertension, organic heart disease, and abnormal electrocardiogram; were taking more hypotensive medications; and required more frequently hospitalization (P <.01). We concluded that standardized blood pressure measurement in the ED enabled to strongly implicate orthostatic hypotension as a cause of syncope in 24% of patients with this symptom. Drug-related hypotension was the most frequent cause for this disorder.