Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda

IntroductionThe optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda.Materials and methodsWe enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality.ResultsWe enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73).ConclusionsIn patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.     

Early recognition of sepsis through emergency medical services pre-hospital screening

BackgroundThe Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance.ObjectivesTo determine if pre-hospital sepsis screening improves 3-hour bundle compliance.MethodsProspective implementation of an EMS sepsis screening tool (June 2016–November 2016) was compared to a historical control (August 2015–March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components.ResultsOf 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2–8] vs. 2 [IQR 1–4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0–35] vs. 46 min [IQR 34–57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0–38] vs. 46 min [IQR 27.5–72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44–92] vs. 72 min [IQR 59.5–112], p = 0.26).ConclusionImplementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.     

Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study

PurposePatients with severe sepsis and septic shock are at high risk for development of pulmonary complications, including acute respiratory distress syndrome (ARDS). Serial lactate monitoring is a useful tool to gauge global tissue hypoxia in emergency department (ED) patients with sepsis. We hypothesized that patients undergoing serial lactate monitoring (SL) would demonstrate a decreased incidence of pulmonary complications.MethodsThis is a retrospective observational cohort study of adult severe sepsis and septic shock patients with elevated lactate presenting to a large academic ED. A total of 243 patients were assigned to SL (n = 132) or no serial lactate monitoring (NL; n = 111). The primary outcome was a composite of pulmonary complications: (1) ARDS development and (2) respiratory failure.ResultsTwenty-eight patients (21%) in the SL group and 37 patients (33%) in the NL group developed the primary outcome (P = .03). Multivariate analysis demonstrated an association between the NL group and development of pulmonary complications (adjusted odds ratio [aOR], 2.1; confidence interval [CI], 1.15-3.78). Emergency department mechanical ventilation was independently associated with development of ARDS (aOR, 3.5; 1.8-7.0). In the a priori subgroup of patients mechanically ventilated in the ED (n = 97), those who developed ARDS received higher tidal volumes compared to patients who did not develop ARDS (8.7 mL/kg predicted body weight [interquartile range, 7.6-9.5] vs 7.6 [interquartile range, 6.8-9.0]; P < .01).ConclusionsSerial lactate monitoring is associated with a decrease in major pulmonary complications in severe sepsis and septic shock. Acute respiratory distress syndrome incidence is also influenced by ED-based mechanical ventilation. These results provide 2 potentially modifiable variables to be targeted in future studies to prevent pulmonary complications in this patient subset.     

Prognostic value of PaO2/FiO2, SOFA and D-dimer in elderly patients with sepsis

ObjectiveTo investigate the prognostic value for predicting mortality of partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂), the Sequential Organ Failure Assessment (SOFA) score and D-dimer in elderly patients with sepsis.MethodsThis retrospective cohort study enrolled elderly patients with sepsis admitted to the intensive care unit (ICU) between January 2019 and October 2020. Patients were divided into a survival group and a non-survival group. Biomarkers, SOFA, Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale scores were recorded within 24 h after admission to the ICU.ResultsA total of 135 elderly patients with sepsis were enrolled in the study: 89 were in the survival group and 46 were in the non-survival group at 28 days. Univariate and multivariate regression analyses demonstrated that PaO₂/FiO₂, SOFA and D-dimer were independently associated with 28-day mortality. The predictive performance for mortality of the combination of PaO₂/FiO₂, SOFA score and D-dimer (area under the receiver operating characteristic curve of 0.926) was higher than the values for the individual factors (0.761, 0.745 and 0.878, respectively).ConclusionThe combination of PaO₂/FiO₂, SOFA score and D-dimer represents a promising tool and biomarker for predicting 28-day mortality of the elderly patients with sepsis.     

The impact of emergency medical services on the ED care of severe sepsis

Objective

The identification and treatment of critical illness is often initiated by emergency medical services (EMS) providers. We hypothesized that emergency department (ED) patients with severe sepsis who received EMS care had more rapid recognition and treatment compared to non-EMS patients.

Methods

This was a prospective observational study of ED patients with severe sepsis treated with early goal-directed therapy (EGDT).We included adults with suspected infection, evidence of systemic inflammation, and either hypotension after a fluid bolus or elevated lactate. Prehospital and ED clinical variables and outcomes data were collected. The primary outcome was time to initiation of antibiotics in the ED.

Results

There were 311 patients, with 160 (51.4%) transported by EMS. Emergency medical services-transported patients had more organ failure (Sequential Organ Failure Assessment score, 7.0 vs 6.1; P = .02), shorter time to first antibiotics (111 vs 146 minutes, P = .001), and shorter time from triage to EGDT initiation (119 vs 160 minutes, P = .005) compared to non-EMS-transported patients. Among EMS patients, if the EMS provider indicated a written impression of sepsis, there was a shorter time to antibiotics (70 vs 122 minutes, P = .003) and a shorter time to EGDT initiation (69 vs 131 minutes, P = .001) compared to those without an impression of sepsis.

Conclusions

In this prospective cohort, EMS provided initial care for half of the patients with severe sepsis requiring EGDT. Patients presented by EMS had more organ failure and a shorter time to both antibiotic and EGDT initiation in the ED.     

Lactate and combined parameters for triaging sepsis patients into intensive care facilities

PurposeTo find predictors of intensive care unit (ICU) requirement within the first 48 hours in newly diagnosed sepsis patients presenting at the emergency department.Materials and methodsAnalysis of a prospective observational cohort was performed. We recruited new sepsis patients at the emergency department, and collected baseline characteristics and parameters. Variables were compared between patients: those that required ICU within 48 hours and those that did not. Multivariate analysis was performed to identify independent predictors.ResultsOut of 719 patients enrolled, 275 were confirmed to have sepsis. There were 107 patients (39%) that required ICU admission within 48 hours. Independent predictors for ICU requirement were: lower body temperature (P = .019), initial lactate (P = .02), 2-hour lactate clearance (P = .035), and the Sequential Organ Failure Assessment (SOFA) score without cardiovascular component (SOFA _{no CVS}) (P < .001). The optimal cutoff values for the two strongest predictors were: SOFA _{no CVS} ≥ 5 (adjusted OR, 5.3; 95% CI, 1.9-14.7) and initial lactate ≥ 1.9 mmol/L (adjusted OR, 3.3; 95% CI, 1.2-8.9). We also proposed a combined “LACTIC score” with higher predictive ability.ConclusionsWe suggested a way to predict ICU requirement in sepsis patients and proposed a combined score that might be better than individual parameters. Further validation should be performed before using them clinically.     

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department

BackgroundSepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.ObjectiveTo evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.MethodsWe performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.ResultsOf the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = −0.406; 95% CI = −0.809, −0.003; p = 0.048) and time of triage to physician (coeff = −0.543; 95% CI = −0.864, −0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.ConclusionEMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.     

Beta-blockers' effect on Levels of Lactate in patients with suspected sepsis – The BeLLa study

ObjectiveIn the assessment and management of septic patients in the emergency department (ED), serum lactate is often measured to stratify severity to guide decision making. Increased adrenergic drive has been postulated as a contributory factor for hyperlactatemia in sepsis. We aim to prospectively evaluate the effect of chronic beta-blocker use on serum lactate levels in sepsis at initial presentation to the ED.MethodsWe conducted a prospective observational study at the ED of a tertiary care academic medical center in Singapore. One hundred and ninety-five ED patients who fulfilled all of the following: (1) age 45 years and above, (2) tympanic temperature ≥ 37.8 °C or clinically suspected to have an infection, and (3) quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score ≥ 1 were included in the study. Serum venous lactate was sampled within two hours from presentation to the ED. The primary outcome measure was the difference in initial serum venous lactate concentration at presentation to the ED in patients on chronic beta-blockers versus patients without.ResultsSeventy patients (35.9%) were on long-term beta-blocker therapy. The primary outcome of mean initial serum venous lactate concentration was similar between patients prescribed chronic beta-blocker therapy and patients without (1.78 mmol/L versus 1.70 mmol/L, p = .540). Chronic beta-blocker therapy also did not significantly affect mean initial serum venous lactate concentration across all subgroups of sepsis risk stratification.ConclusionsLong-term beta-blocker therapy did not significantly affect initial serum venous lactate concentration in ED patients with suspected sepsis.     

Comparison of children receiving emergent sepsis care by mode of arrival

ObjectiveTo determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport).MethodsRetrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported.ResultsOf the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days).ConclusionsChildren with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.     

Arterial lactate improves the prognostic performance of severity score systems in septic patients in the ED

Objective

To evaluate the prognostic performance of lactate in septic patients in the emergency department (ED) and investigate how to add lactate to the traditional score systems.

Methods

This was a single-centered, prospective, observational cohort study conducted in ED of Beijing Chao-Yang Hospital. The study enrolled adult septic patients admitted to the ED. Arterial lactate was measured in every patient. Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), and Mortality in Emergency Department Sepsis (MEDS) scores were calculated on ED arrival. The primary outcome was 28-day mortality.

Results

The average levels of lactate, MEDS, APACHE II, and SOFA were much higher in nonsurvivors than in survivors (P < .001), and they were the independent predictors of 28-day mortality. Area under receiver operating characteristic (AUC) curves of MEDS, APACHE II, SOFA, and lactate were 0.74, 0.74, 0.75, and 0.79, respectively. The AUCs of combination lactate and MEDS, APACHE II, and SOFA were 0.81, 0.81, and 0.82, respectively and were much higher than that of score systems alone (P < .05). The AUCs of modified MEDS, APACHE II, and SOFA were 0.80, 0.80, and 0.81, respectively. The prognostic value of the modified score systems was superior to the original score systems and similar to the combination of the lactate and original score systems.

Conclusions

Lactate is a prognostic predictor in septic patients in the ED, and it may improve the performance of APACHE II, SOFA, and MEDS scores in predicting mortality.     

Opportunities for Emergency Medical Services care of sepsis

Objective

Emergency Medical Services (EMS) systems play key roles in the rapid identification and treatment of critical illness such as trauma, myocardial infarction and stroke. EMS often provides care for sepsis, a life-threatening sequelae of infection. In this study of Emergency Department patients admitted to the hospital with an infection, we characterized the patients receiving initial care by EMS.

Methods

We prospectively studied patients with suspected infection presenting to a 50,000 visit urban, academic ED from September 16, 2005-September 30, 2006. We included patients who had abnormal ED vital signs or required hospital admission. We identified patients that received EMS care. Between EMS and non-EMS patients, we compared patient age, sex, nursing home residency, vital signs, comorbidities, source of infection, organ dysfunction, sepsis severity and mortality. We analyzed the data using univariate odds ratios, the Wilcoxon rank-sum test and multivariate logistic regression.

Results

Of 4613 ED patients presenting with serious infections, 1576 (34.2%) received initial EMS care. The mortality rate among those transported by EMS was 126/1576 (8.0%) compared to 67/3037 (2.2%) in those who were not. Adjusted mortality was higher for EMS (OR 1.8, 95% CI: 1.3-2.6). Of patients who qualified for protocolized sepsis care in the ED, 99/162 (61.1%) were transported via EMS. EMS patients were more likely to present with severe sepsis (OR 3.9; 3.4-4.5) or septic shock (OR 3.6; 2.6-5.0). EMS patients had higher sepsis acuity (mortality in ED sepsis score 6 vs. 3, p < 0.001).

Conclusions

EMS provides initial care for over one-third of ED infection patients, including the majority of patients with severe sepsis, septic shock, and those who ultimately die. EMS systems may offer important opportunities for advancing sepsis diagnosis and care.     

Prognostic Accuracy of Quick SOFA is different according to the severity of illness in infectious patients

BackgroundSepsis-3 proposed the quick Sequential Organ Failure Assessment (qSOFA) to identify sepsis patients likely to have poor outcome. The clinical utility of qSOFA still remains controversial because its predictive accuracy for mortality is quite different across the validation studies. We hypothesized that one of the major causes for these controversial findings was the heterogeneity in severity across the studies, and evaluated the association between severity of illness and the prognostic accuracy of qSOFA.Materials and methodsThis was a post hoc analysis of a prospective nationwide cohort of consecutive adult patients with sepsis in 59 intensive care units in Japan. Regression trees analysis for survival was used to classify patients according to severity of illness as determined by SOFA score on registration. We conducted receiver operating characteristic (ROC) analyses and evaluated the differences in the area under the ROC curve (AUROC). As a subgroup analysis, we conducted the above evaluations in emergency department (ED) and non-ED patients separately.ResultsWe included 1114 patients fulfilling the criteria and classified them into three subsets according to severity. The AUROC for mortality was significantly different according to the severity of illness (p = 0.007), with the highest AUROC being in the low-severity subset (patients with SOFA score ≤ 7). Interestingly, our subgroup analysis revealed that a significant difference in the AUROC of qSOFA was observed only in ED patients.ConclusionThis study suggested that lower severity of illness was associated with the relatively higher prognostic accuracy of qSOFA, especially in ED patients.     

Sepsis alerts in EMS and the results of pre-hospital ETCO2

BackgroundField sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection.MethodsIn 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a “sepsis alert” on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2.Results351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was −0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population.ConclusionWhile ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.     

Time to antibiotic administration: Sepsis alerts called in emergency department versus in the field via emergency medical services

IntroductionThe Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) identifies patients with “severe sepsis” and mandates antibiotics within a specific time window. Rapid time to administration of antibiotics may improve patient outcomes. The goal of this investigation was to compare time to antibiotic administration when sepsis alerts are called in the emergency department (ED) with those called in the field by emergency medical services (EMS).MethodsThis was a multi-center, retrospective review of patients designated as sepsis alerts in ED or via EMS in the field, presenting to four community emergency departments over a six-month period.Results507 patients were included, 419 in the ED alert group and 88 in the field alert group. Mean time to antibiotic administration was significantly faster in the field alert group when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs 44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates, fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic utilization rates were not found to be significantly different.ConclusionsSepsis alerts called in the field via EMS may decrease time to antibiotics and increase the likelihood of antibiotic administration occurring within 60 min of arrival when compared to those called in the ED.     

Pre-resuscitation Lactate and Hospital Mortality in Prehospital Patients

Abstract

Objective. Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (IV) resuscitation and examine the association of elevation on in-hospital death. Methods. A convenience sample of adult patients over 14 months who received an IV line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any IV treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. Results. We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). Conclusions. Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.     

Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Background

Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel.

Objective

This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated.

Methods

We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study.

Results

Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14–8.88; p = 0.040).

Conclusions

This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality.     

Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank

Background

The prevalence and impact of prehospital neurologic deterioration (PhND) in patients with traumatic brain injury (TBI) have not been investigated. We aimed to determine the prevalence of PhND during emergency medical service (EMS) transportation among patients with TBI and its impact on patient's outcome.

Methods

We used the National Trauma Data Bank, using data files from 2009 to 2010 to identify patients with TBI through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The initial Glasgow Coma Scale (GCS) score ascertained at the scene by EMS was compared with the subsequent GCS score evaluation in the emergency department (ED) to identify neurologic deterioration (defined as a decrease in GCS of ≥ 2 points). Patients' demographics, initial injury severity score (ISS), admission GCS score, and hospital outcome were compared between patients with PhND and patients without neurologic deterioration.

Results

A total of 257?127 patients with TBI were identified. Among patients with TBI, 22?254 patients had PhND, which comprised 9% of all patients with TBI. The mean of GCS score decrease during EMS transport was 5 points (± 3). Patients without PhND tended to have higher GCS recorded by EMS (median, 15 vs 12; P < .0001). Patients with TBI who had PhND had significantly higher hospital length of stay and intensive care unit days after adjusting for baseline characteristics and EMS GCS score, EMS transport time, type of injury, presence of intracranial hemorrhages, and ED ISS (P < .0001). These patients had higher rate of in-hospital mortality after adjusting for the same variables (odds ratio, 2.30; 95% confidence interval, 2.18-2.41).

Conclusion

Prehospital neurologic deterioration occurs in 9% of patients with TBI. It is more prevalent in men and associated with lower EMS GCS level and higher ED ISS. Prehospital neurologic deterioration is an independent predictor of worse hospital outcome and higher resource use in patients with TBI.     

Serum neuron-specific enolase levels at presentation and long-term neurological sequelae after acute charcoal burning-induced carbon monoxide poisoning

Objective: This study aimed to investigate whether clinical parameters and serum neuron-specific enolase (NSE) levels measured at emergency department (ED) presentation help stratify the risk of acute or delayed persistent severe neurological sequelae after acute carbon monoxide (CO) poisoning induced by charcoal burning.

Methods: This retrospective study included 236 patients who suffered from CO poisoning. Demographic information, serum NSE levels measured in the ED, treatment, clinical course, and long-term neurological outcomes were recorded.

Results: The median serum NSE level at presentation was 15.5 (10.9–22.7) ng/mL. No differences were observed in the duration of CO exposure; the initial Glasgow Coma Scale (GCS) score; the levels of arterial HCO₃^?, white blood cells (WBCs), C-reactive protein (CRP) or troponin I; or the frequency of abnormal diffusion-weighted imaging finding at presentation among the groups with different serum NSE levels at presentation. The incidences of acute and delayed persistent neurologic sequelae assessed at 22.3 months after acute charcoal CO poisoning were 5.1% and 8.5%, respectively. No difference in the NSE level was observed between patients stratified according to long-term neurological status. According to the multinomial logistic regression analysis, age, serum CRP levels and the initial GCS score were risk factors for the two types of persistent severe neurological sequelae, whereas troponin I levels were associated only with the acute persistent severe neurological sequelae. However, the adjusted NSE level was not a risk factor for any persistent neurological sequelae.

Conclusions: Serum NSE levels at presentation were not correlated with the risk of acute or delayed persistent neurological sequelae. Further studies with blood sampling at optimal time points and serial measurements should be conducted. Age, initial GCS score, and CRP levels may be risk factors for persistent severe neurological sequelae.     

Glasgow Coma Scale score of more than four on admission predicts in-hospital survival in patients after out-of-hospital cardiac arrest

AimThe aim of the study was to assess the usefulness of the Glasgow Coma Scale (GCS) score assessed by EMS team in predicting survival to hospital discharge in patients after out-of-hospital cardiac arrest (OHCA).MethodsSilesian Registry of OHCA (SIL-OHCA) is a prospective, population-based regional registry of OHCAs. All cases of OHCAs between the 1st of January 2018 and the 31st of December 2018 were included. Data were collected by EMS using a paper-based, Utstein-style form. OHCA patients aged ≥18 years, with CPR attempted or continued by EMS, who survived to hospital admission, were included in the current analysis. Patients who did not achieve return of spontaneous circulation (ROSC) in the field, with missing data on GCS after ROSC or survival status at discharge were excluded from the study.ResultsTwo hundred eighteen patients with OHCA, who achieved ROSC, were included in the present analysis. ROC analysis revealed GCS = 4 as a cut-off value in predicting survival to discharge (AUC 0.735; 95%CI 0.655–0.816; p < 0.001). Variables significantly associated with in-hospital survival were young age, short response time, witnessed event, previous myocardial infarction, chest pain before OHCA, initial shockable rhythm, coronary angiography, and GCS > 4. On the other hand, epinephrine administration, intubation, the need for dispatching two ambulances, and/or a physician-staffed ambulance were associated with a worse prognosis. Multivariable logistic regression analysis revealed GCS > 4 as an independent predictor of in-hospital survival after OHCA (OR of 6.4; 95% CI 2.0–20.3; p < 0.0001). Other independent predictors of survival were the lack of epinephrine administration, previous myocardial infarction, coronary angiography, and the patient's age.ConclusionThe survival to hospital discharge after OHCA could be predicted by the GCS score on hospital admission.     

Predictive factors for acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning

BackgroundAcute brain lesions on diffusion-weighted-magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning were associated with delayed neurological sequelae. This study was conducted to identify the risk factors associated with acute brain lesions on MRI after acute CO poisoning and to help select patients who need acute-phase brain MRI after acute CO poisoning in the emergency department (ED).MethodsThis retrospective observational study included 103 adult patients who were hospitalized at a tertiary-care hospital between November 2016 and September 2019 and underwent brain MRI because of acute CO poisoning. Multivariable logistic regression analysis was applied to identify predictive factors for acute brain lesions on MRI after acute CO poisoning.ResultsMultivariable logistic regression analysis showed that Glasgow Coma Scale (GCS) score of <9 at ED presentation (odds ratio [OR] 17.749, 95% confidence interval [CI] 3.098–101.690, P = 0.001) and the initial troponin-I level at presentation in the ED (OR 13.657, 95% CI 1.415–131.834, P = 0.024) were predictive factors for acute brain lesions on MRI in acute CO poisoning. The receiver operating characteristics curve for initial troponin-I showed an area under the curve of 0.761 (95% CI 0.638–0.883, P < 0.001) and the optimal cutoff value was 0.105 ng/mL.ConclusionsAcute-phase brain MRI in acute CO poisoning can be considered for patients who present at the ED with a GCS score <9 or troponin-I level >0.105 ng/mL.