Incidence, Outcomes, and Risk Factors of Post-Intubation Hypotension in Adult Trauma Patients

Kaley K. El-Arab, MD, Huaping Wang, PhD, Alan C. Heffner, MD, Michael Gibbs, MD, Kyle W. Cunningham, MD MPH

Introduction: Cardiovascular deterioration is a recognized complication of emergency intubation. Post-intubation hypotension (PIH) has not been investigated in acute trauma resuscitation. We aim to identify the incidence, risk factors, and outcomes associated with PIH in acute resuscitations of injured patients.

Methods: We conducted a retrospective health records review of consecutive patients presenting with traumatic mechanisms requiring emergency airway management from January 2020 to October 2021. Data were extracted via the trauma database and manual chart review using a standard data collection instrument and a single reviewer. Enrolled patients were 18 years or older, involved in trauma, and intubated in the Emergency Department. Patients with hypotension defined by systolic blood pressure (SBP) < 90 mmHg, use of vasopressors, or cardiac arrest prior to intubation or within 30 minutes of intubation were excluded. PIH was defined as SBP < 90 mmHg within 30 minutes of intubation. Patients with PIH were compared to those who did not experience PIH.

Results: We identified 540 patients in our trauma database; 294 patients met criteria for the study. The median patient age was 38 years old and 77.6% of patients were male. PIH occurred in 36 of 294 (12.2%) patients.

Patients experiencing PIH did not have statistically higher mortality; 22.2% versus 16% (difference of 6.2%; 95% CI -0.19-0.07; p=0.34), but the median total hospital length of stay was 2.5 days longer for patients with PIH (8.5 IQR(3.5-23) versus 6 IQR(2-14); p=0.04). PIH patients had higher pre-intubation shock index (0.8 versus 0.7 p=<0.01), were less likely to be intubated on first attempt (77.1% versus 94.9%; p=<0.01), and were more likely to be female (56% versus 18%; p <0.01).

Discussion: PIH is a common complication of emergency intubation in trauma patients and is associated with higher complexity of illness as identified by hospital length of stay. We identified several clinical risk factors associated with PIH in trauma patients.

Precordial Swirl Sign: A new ECG pattern of LAD OMI

Lucas Goss, MD, H. Pendell Meyers, MD, Brandon Friedman, MD, Alexander Bracey, MD, Daniel Lee, MD, Andrew Lichtenheld, MD, Wei J. Li, MD, Daniel D. Singer, MD, Jesse A. Kane, MD, Kenneth W. Dodd, MD, Kristen E. Meyers, MENG, Henry C. Thode, PHD, Gautam R. Shroff, MD, MBBS, FACC, Adam J. Singer, MD, and Stephen W. Smith, MD

Objectives: We sought to describe and evaluate a new ECG pattern of subtle left anterior descending (LAD) occlusion called “precordial swirl.” In this pattern the ECG manifests abnormal ST elevation (STE) and/or hyperacute T waves in V1-V2, with reciprocal STD and/or TWI in V5-V6, creating a clockwise “swirl” pattern in the ST-T shifts of the precordial leads (V1-V6).

Methods: After deriving the description and characteristics of the precordial swirl pattern from 15 patients with proven acute LAD occlusion correlating with the pattern, the pattern was evaluated using a high-risk population of ED patients with possible ACS symptoms. Amplitude and morphology of the ST segment, QRS complex and T wave were measured. We hypothesized that our derived criteria for precordial swirl pattern would have clinically significant specificity (greater than 90%) for OMI due to LAD occlusion.

Results: Several criteria were derived based on observations and measurements of the derivation cohort. The validation cohort consisted of 808 patients, of whom 265 had OMI. Precordial swirl defined as normal QRS (narrow QRS without LVH) with STD in V5 and/or V6 plus STE in V1 and/or V2 yielded a sensitivity and specificity of 11% (95% CI 8-15%) and 93% (95% CI 90-95%) for OMI. Positive and negative likelihood ratios were 1.54 (95% CI 0.98-2.41) and 0.96 (95% CI 0.91-1.00) Furthermore, this pattern correctly identified 13% of all STEMI (-) OMI in the validation cohort. Other derived criteria had similarly high specificity. T/QRS and STE/QRS ratios in V1 and V2 were significantly higher in subjects found to have OMI suggesting a relationship between the ratio of the amplitude of T wave and ST segment in acute coronary occlusion.

Conclusions: Among high-risk ACS patients in the ED, various definitions of the proposed “precordial swirl” sign had high specificity for LAD OMI, including a significant number of patients who are missed by the current STEMI criteria. Further study should be done to validate these findings and improve detection of acute coronary occlusion myocardial infarction.

Sexually Transmitted Infection Testing Differences Between Community and Academic Emergency Department Settings

Anthony James, Jeremy Thomas, Thomas Ludden

Background: Sexually transmitted infections (STIs) remain a common reason for presentation to the emergency department (ED). Isolated STI testing fails to address the concurrent risk factors that gonorrhea, chlamydia, syphilis, and HIV share. Patients undergoing STI testing can present to various ED configurations including academic sites or community sites. The study objective was to examine differences in STI testing between an academic ED and an associated community ED.

Methods: Gonorrhea and chlamydia, syphilis, and HIV testing rates were calculated for both an academic and a community ED for the years 2019‐2022. Rates of comprehensive testing (testing for all four STIs during a single encounter) were also compared to rates of isolated STI testing between the two EDs.

Results: The academic ED averaged 6.45 comprehensive tests per 1,000 patients (95% CI 6.07‐ 6.88) whereas the community site averaged 1.39 per 1,000 patients (95% CI 1.13‐1.65). Isolated testing for gonorrhea and chlamydia at the community ED was 67.6 per 1,000 patients (95% CI 65.8‐69.4) vs 39.68 per 1,000 patients (95% CI 38.7‐40.7) at the academic site. Co‐Testing for syphilis and HIV was over 70.0% (95% CI 68.0‐72.0) at the academic ED vs 51.9% (95% CI 45.6‐ 58.2) at the community ED. Men were less likely to receive isolated testing at the academic ED, 60.5% (95% CI 58.0‐63.0) compared to the community ED with 94.3% (95 CI 93.1‐95.5).

Conclusion: Comprehensive testing rates at both sites were lower than isolated testing for gonorrhea and chlamydia indicating an opportunity for interventions to increase HIV screening within both ED settings.

Teen Trauma Outcomes in the Adult verses Pediatric Emergency Department at Carolinas Medical Center

Breeanna Lorenzen, MD; Samuel Ross, MD; Christyn Magill, MD

Objective: To compare “Teen Trauma” outcomes, outcomes from adolescents ages 1518 presenting with trauma, in the Adult verses Pediatric Emergency Department at Carolinas Medical Center.

Introduction: There is still debate if adolescents who present with trauma are better served in Adult Trauma Centers (ATCs) or Pediatric Trauma Centers (PTCs). The evidence continues to present conflicting results. Most studies compare separate ATCs vs PTCs but exclude data from combined trauma centers. Carolinas Medical Center is unique because it is a combined trauma center. Additionally, from January 2021-January 2022, adolescents ages 15-18 presenting with trauma were seen on the adult side of the emergency department. However, from February 2022-February 2023, this age group was treated on the pediatric side, providing a rare opportunity to be able to compare outcomes.

Methods: This study was a retrospective observational analysis of injured adolescents ages 15-18 presenting to the Carolinas Medical Center Emergency Department as a Trauma Code 1 or Trauma Code 2. Transfers, Trauma Alerts, those that dead on arrival and those with incomplete charts were excluded. The data was stratified by year, January 2021-January 2022 (when teen traumas were seen on the adult side) and February 2022February 2023 (when teen traumas were seen on the pediatric side.) Data was also stratified by Trauma Code 1 verses Trauma Code 2. Primary outcomes were emergency department (ED) and in-patient (IP) mortality. Secondary outcomes included ED length of stay (LOS), total ventilator days, total ICU days, and process outcomes including whether patients were intubated in the ED, had central accesses placed in the ED, had a chest tube placed in the ED, had a massive transfusion protocol initiated in the ED, if they had a FAST exam performed, or if pain medications were given. Additionally, the number of both CT scans and X-rays ordered in the ED were analyzed.

Results: A total of 157 adolescents ages 15-18 were included (73 from January 2021January 2022 and 84 from February 2022-February 2023.) There was a significant difference in overall ED mortality (2/73 January 2021-January 2022 and 0/84 February 2022-February 2023) vs inpatient mortality (4/73 January 2021-January 2022 and 5/84 February 2022-February 2023), p=.003. However, there were no significant difference in overall mortality between January 2021-January 2022 (6/73) and February 2022-February 2023 (5/84), p=.58. There was also no significant difference in ED length of stay (172 average minutes (IQR 71-258) vs 195.5 minutes (IQR 112-268), p=.72), total ventilator days for Trauma Code 1 (2 average days (1-3 days) vs 2 average days (1.5-3 days), p=.36) or total ICU days (Trauma Code 1 average days 2.5 (2-4 days), p=.35 and Trauma Code 2 average days 2.5 (2-4 days), p=.88.) The only process outcome that showed a significant difference between the time frames, was the total number of X-rays ordered during Trauma Code 2s (average 2 (1-3) vs 3 (1-5)), p= .01.

Conclusions: The only significant differences were in ED vs inpatient mortality and in the total number of X-rays ordered during Trauma Code 2s. Otherwise, there were no significant differences in primary or secondary outcomes when adolescents ages 15-18 with trauma were treated in the Adult verses Pediatric Emergency Department at Carolinas Medical Center.

GO-PAP® versus Flow-Safe®: Which is Better?

Quinton Nannet MD Carolinas Medical Center, Joseph Blackwell MD Carolinas Medical Center and Mecklenburg EMS Agency, Melanie Hogg Carolinas Medical Center, Jonathan Studnek Mecklenburg EMS Agency, Douglas Swanson MD Carolinas Medical Center and Mecklenburg EMS Agency.

Objectives: It is estimated that between 3%-9% of Emergency Department visits and 7%-12% of hospital admissions are due to patients presenting with a primary respiratory complaint (Kelly, Langlo). Prehospital CPAP administration has been shown to reduce endotracheal intubations and reduce absolute mortality by as much as 18%-30% and 7%-21% respectively (Thompson, Winck). This retrospective cohort review compares need for endotracheal intubation (NETI), in-hospital mortality, hospital admission rates, and prehospital provider assessment of improvement between two popular pre-hospital CPAP devices administered to patients in respiratory distress.

Methods: Chart review was performed on patients that required pre-hospital CPAP for undifferentiated respiratory distress. Two independent 6-month periods of data were extracted, including 323 patient encounters in which FLOW-SAFE® was implemented and 348 patient encounters which GO-PAP® was utilized. Any patients over the age of 18 that received CPAP were included. The only exclusion criteria were patients under the age of 18. Prehospital providers assessed initial and final respiratory rate (RR) and pulse oximetry (SPO2) as well as a clinical assessment of respiratory status after intervention. Clinical outcomes of ED disposition, Intubation, and In-hospital mortality rates were collected via chart review amongst patients transported to our health care system.

Results: 670 total patient encounters were measured with 323 receiving FLOWSAFE® and 347 receiving GO-PAP® with no statistically significant differences in sample demographics of age, sex, and racial identity. EMS interpretation of clinical improvement in respiratory status showed no statistical significance 77.7% vs 73.5% (p = 0.125). Amongst the 670 total patients, 547 (81.6%) of them were transported to facilities where we had access to chart review. Of this subgroup, there was no statistically significant difference between FLOW-SAFE® and GO-PAP® in clinical outcomes of ED admission 89.8% vs 92.4% (p = 0.437), NETI 19.9% vs 14.3% (p = 0.121) or in-hospital mortality 10.2% vs 8.9% (p = 0.651).

Conclusion: Amongst this retrospective cohort, which is the largest head-to-head prehospital CPAP Device comparison study to date there was no statistically significant difference between FLOW-SAFE® or GO-PAP® in clinical outcomes of ED Admission, NETI, in-hospital mortality rates or EMS provider perceived clinical improvement.

Active Normothermic Targeted Temperature Management Following Cardiac Arrest Is Associated With High Fever Rate

Dominic Nicacio, MD1 , Alan Heffner, MD1,2 , Tsai-Wei Wang, MS3 , Kathi Kraft, RN3 , Leslie London, RN4 , David Pearson MD, MS, MBA 1

1 Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center

2 Department of Internal Medicine, Pulmonary & Critical Care Consultants, Atrium Health’s Carolinas Medical Center

3 Informatics & Analytics Services (IAS), Atrium Health

4 Emergency Medicine, Atrium Health

Background: Recent evidence supports active normothermic targeted temperature management (TTM) in patients after out-of-hospital cardiac arrest (OHCA). In July 2021, our institution transitioned to TTM targeting 37◦C. Our objective was to evaluate the impact of this practice change on temperature control and patient outcome.

Methods: This retrospective cohort study evaluated patients prospectively enrolled in an institutional registry and clinical pathway of consecutive patients admitted to the ICU following out of hospital cardiac arrest (OHCA) from July 1, 2014 to November 30, 2022. We compared a period of hypothermic TTM targeting 33◦C to 36◦C to a post-intervention period of normothermic TTM targeting 37◦C. The primary outcome was good neurological outcome at hospital discharge, with a secondary outcome of temperature control and avoidance of fever (≥ 38.0◦C) in the normothermia cohort.

Results: Of 1672 OHCA patients during the study period, 1610 (96%) had complete data and were included in the analysis. Mean age was 57 years and 1052 (63%) were male. Among all patients, witnessed arrest occurred in 1236 (77%), 730 (45%) had an initial shockable rhythm, and 553 (34%) had a good neurologic outcome. There was no difference in good neurological outcome between the hypothermia cohort (487/1426, 34.2%) and normothermia cohort (66/184, 35.9%) (absolute difference 1.7%, P=0.59). Among patients with witnessed OHCA and initial shockable rhythm, there was also no difference in good neurologic outcome between the cohorts (22.4% vs 20.6%; absolute difference 1.8%, P=0.38). After TTM target change, fewer patients received active TTM with a device (99.9% vs 58.2%, P<0.0001) and more patients experienced fever (0% vs 33.2%, P<0.0001) with a median duration of 180 minutes (IQR: 90 – 435 minutes).

Conclusion: After transition to 37◦C TTM target, OHCA patients experienced a significant increase in rate of fever. There was no difference in neurologic outcome between the hypothermia and normothermia cohorts. The precision and use of cooling devices may be important considerations for temperature control when choosing a target temperature.