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Background Many patients with Coronavirus disease-2019 (Covid-19) present with radiological evidence of pneumonia. Because it is difficult to determine co-existence of bacterial pneumonia, many of these patients are initially treated with antibiotics. We compared the rates of bacterial infections and mortality in Covid-19 patients with pulmonary infiltrates versus patients diagnosed with ‘pneumonia’ the year previously. Methods We conducted a medical record review of patients admitted with Covid-19 and a pulmonary infiltrate and compared them with patients diagnosed with pneumonia admitted in the prior year before the pandemic. Data abstracted included baseline demographics, comorbidities, signs and symptoms, laboratory and microbiological results, and imaging findings. Outcomes were bacterial infections and mortality. Patients presenting with and without Covid-19 were compared using univariable and multivariable analyses. Results There were 1398 and 1001 patients admitted through the emergency department (ED) with and without Covid-19 respectively. Compared with non-Covid-19 patients, those with Covid-19 were younger (61±18 vs. 65±25 years, P

Introduction Computed tomography (CT) is often ordered for patients in whom the diagnosis of acute pancreatitis (AP) has already been established via elevated lipase levels and typical abdominal pain. We investigated whether early CT imaging performed in the ED altered the diagnosis or management. Methods A retrospective chart review was performed on patients presenting to a large, academic ED between the years 2013–2015 with AP who received CT imaging. Relevant history, laboratory, imaging data, and hospital course were abstracted from the medical record and analyzed by three independent reviewers, with 100% agreement among reviewers on 30 randomly selected cases. The primary outcome was whether the CT led to a change in diagnosis or management above and beyond the ultrasound. Univariate and multivariate analyses were performed to determine association between predictor variables and outcomes. Results The electronic health record query yielded 458 patients. Of those, 174 met the American College of Gastroenterology criteria for AP and were included in the study. 145 patients (83%) had abdominal CT during their hospital course, 125 (86%) of which were performed in the ED. Of these 145 patients, 57 (39%) had imaging evidence of AP. 107 patients had abdominal ultrasound (US) during their hospital course. Of 84 patients who had both CT and US, 31 (37%) patients were diagnosed with gallstones by US versus 19 (23%) by CT. Biliary dilation/obstruction was diagnosed by US in 5 (6%) patients versus 4 (5%) by CT. CT led to the correct diagnosis or change in management in 21 (14.5%) patients. Conclusion Early CT may alter the diagnosis or management in up to 15% of patients presenting to the ED with AP, especially older patients with prior episodes of pancreatitis and biliary interventions, however abdominal US may be a more sensitive screening study for biliary etiologies and thereby better direct further management.

ObjectiveOverreliance on technology has led to dwindling physical exam (PE) skills. We compared the diagnostic accuracy of a structured lung physical examination (L-PE) to structured lung ultrasound (LUS) in ED patients with undifferentiated dyspnea. We also examined the change in differential diagnosis and degree of certainty based on order and type of examMethodsThis was a prospective, randomized, crossover study of a convenience sample of adult ED patients with undifferentiated dyspnea. Comprehensive L-PE and LUS were performed in random order followed by the other exam. An adjudication committee determined the final diagnosis based on all available data and served as the criterion standard. Primary outcome was diagnostic accuracy. A sample of 86 patients had 80% power to detect a 25% difference in diagnostic accuracy.ResultsA total of 102 patients were enrolled. Similar accuracies were found between L-PE and LUS for both COPD [75% (95% CI 65-83) vs. 76% (95% CI 67-84)] and asthma [87% (95% CI 79-93) vs. 87% (95 CI 79-93)]. LUS [81% (95 CI 72-88)] was slightly more accurate compared to L-PE [72% (95 CI 62-80)] for diagnosis of pneumonia but not statistically significant. For patients presenting with pulmonary edema, LUS was slightly [76% (95 CI 66-84)] more accurate than L-PE [73% (95 CI 63-81)], but not statistically significant. Finally, for detecting pleural effusions, L-PE [96% (95 CI 90-99)] was more accurate than LUS [82% (95 CI 73-89)].ConclusionsThe diagnostic accuracies of comprehensive lung physical examination and focused lung ultrasound were generally similar in ED patients with dyspnea and should be used concurrently to maximize diagnostic accuracy.

Background: Respiratory failure due to coronavirus disease of 2019 (COVID-19) often presents with worsening gas exchange over a period of days. Once patients require mechanical ventilation (MV), the temporal change in gas exchange and its relation to clinical outcome is poorly described. We investigated whether gas exchange over the first 5 days of MV is associated with mortality and ventilator-free days at 28 days in COVID-19. Methods: In a cohort of 294 COVID-19 patients, we used data during the first 5 days of MV to calculate 4 daily respiratory scores: PaO2/FiO2 (P/F), oxygenation index (OI), ventilatory ratio (VR), and Murray lung injury score. The association between these scores at early (days 1-3) and late (days 4-5) time points with mortality was evaluated using logistic regression, adjusted for demographics. Correlation with ventilator-free days was assessed (Spearman rank-order coefficients). Results: Overall mortality was 47.6%. Nonsurvivors were older ( P 2 and PaCO2 were similar during this timeframe. However, by days 4 to 5 values for all airway pressures and FiO2 had diverged, trending lower in survivors and higher in nonsurvivors. The most substantial between-group difference was the temporal change in OI, improving 15% in survivors and worsening 11% in nonsurvivors ( P 2 and the intensity of MV, is a potential marker of outcome in respiratory failure due to COVID-19.

The current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI).We aimed to compare the two paradigms within a single population. We hypothesized that STEMI(-) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization.We performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0-2 flow or TIMI 3 flow plus peak troponin T 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes.Among 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(-) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18-7.63), 1.87 (IQR 1.12-5.48), and 0.00 (IQR 0.00-0.08). Median time from arrival to catheterization was 41 min (IQR 23-86 min) for STEMI(+) OMI compared with 437 min (IQR 85-1590 min) for STEMI(-) OMI (p 0.001). STEMI(+) OMI was more likely than STEMI(-) OMI to undergo catheterization within 90 min (76% vs. 28%; p 0.001).STEMI(-) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(-) OMI.

Background Hyperkalemia (HK) is common and associated with mortality. Our purpose was to determine if the rapid correction of elevated serum potassium level (K+) was associated with reduced mortality in emergency department (ED) patients. Methods Design: We reviewed the electronic medical records (EMR) of ED patients with HK (K+ ≥ 5.5 mEq/L) from 10/2016–10/2017. Setting: Large, academic ED. Participants: Adult ED patients presenting with hyperkalemia. Main outcomes and measures: The main outcome was in-hospital mortality. We compared outcomes of patients whose K+ normalized (dropped below 5.5 mEq/L) with those whose K+ did not normalize using chi-square and multivariate analyses to determine the associations between predictor variables and outcomes. Results From 114,977 ED visits, 1033 patients (0.9%, 95%CI 0.85–0.95%) had HK. Their mean (SD) age was 60 (26) years and 58% were male. Of these, 884 had a second K+ measured within a median (IQR) of 5 (3–8) hours. Mortality and admission rates were higher in patients with HK vs. those with normal K+ (8.5% vs. 0.8%, P Conclusions Normalization of K+ during the ED stay in patients with HK is associated with a 50% mortality reduction. Efforts to rapidly identify and treat HK in the ED are needed.

Background Over the last decade the usage of computed tomography (CT) imaging has risen dramatically in emergency department (ED) patients with abdominal pain. Recognizing the potential disadvantages of overuse of CT imaging, efforts are being made to reduce imaging. Objective We determined the operating characteristics for location of abdominal pain for the entities of acute appendicitis, diverticulitis, and intestinal obstruction. We hypothesized that patients with pain localized to the upper abdomen would be less likely to have CT abnormalities than those with lower abdominal pain. Methods This is a prospective, observational registry of ED patients with abdominal pain, performed in an academic, suburban ED with an annual census of 110,000. Presence of clinically significant CT abnormalities (e.g., appendicitis, diverticulitis, bowel obstruction) were recorded along with clinical variables including laboratory values, vital signs, reported location of pain, location of tenderness on examination, and physician pretest probability. Results A convenience sample of 1154 patients was enrolled. Of all patients, 273 cases (24%) had abnormal CT results, including appendicitis (n = 95), diverticulitis (n = 133), and bowel obstruction (n = 49). Right upper quadrant pain was negatively associated with abnormal CT (p = 0.02). Clinician gestalt was highly specific, but lacked sensitivity for the diagnosis of appendicitis, diverticulitis, and obstruction. Twenty-four percent of patients diagnosed with appendicitis had no right lower quadrant pain or tenderness, and 7% of patients with diverticulitis had no left lower quadrant pain or tenderness. Conclusions Localization of abdominal pain by history or physical examination is not sufficient to accurately diagnose intra-abdominal pathology, especially cases of acute appendicitis, diverticulitis, or intestinal obstruction.

Study objective Shoulder dislocations are a common injury leading to emergency department presentations. Point-of-care ultrasonography has the potential to reduce radiation and time to diagnosis. We determine the accuracy of a novel point-of-care ultrasonographic technique to diagnose dislocated shoulders. We also investigate its accuracy to detect fractures, time to image acquisition, the optimal cutoff for the glenohumeral distance, and compare the time to diagnose dislocations from triage between point-of-care ultrasonography and radiography. Methods This was a multicenter prospective observational study. Ultrasonography fellows and fellowship-trained physicians enrolled a convenience sample of patients with suspected shoulder dislocation. Point-of-care ultrasonography was performed with a novel posterior approach with either a curvilinear or a linear transducer. Shoulder dislocation was confirmed with a 3-view radiograph interpreted by an independent radiologist. Sensitivity, specificity, positive predictive values, and negative predictive values were determined for point-of-care ultrasonography, with radiography as the criterion standard. Time to image acquisition, presence or absence of fracture, glenohumeral distance, sonographer confidence, and difference in time to diagnosis from triage for point-of-care ultrasonography and radiograph were also determined. A second investigator independently reviewed all images and interobserver agreement was calculated. Results Sixty-five patients were enrolled in the study. The sensitivity and specificity of point-of-care ultrasonography for identifying dislocations were 100% (95% confidence interval [CI] 87% to 100%) and 100% (95% CI 87% to 100%), respectively. Point-of-care ultrasonography was 92% sensitive (95% CI 60% to 99.6%) and 100% specific (95% CI 92% to 100%) for non–Hill-Sachs/Bankart’s fractures of the humerus. Point-of-care ultrasonography was faster from triage than standard radiology in diagnosing dislocations (median difference 43 minutes; interquartile range [IQR] 23 to 60 minutes). The median total time required for diagnosis by point-of-care ultrasonography was 19 seconds (IQR 10 to 36 seconds). The median glenohumeral distance was –1.83 cm (IQR –1.98 to –1.41 cm) in anterior dislocations, 0.22 cm (IQR 0.10 to 0.35 cm) on nondislocated shoulders, and 3.30 cm (IQR 2.59 to 4.00 cm) in posterior dislocations. Conclusion A posterior approach point-of-care ultrasonographic study is a quick and accurate tool to diagnose dislocated shoulders. Ultrasonography was also able to accurately identify humeral fractures and significantly reduce the time to diagnosis from triage compared with standard radiography.

Laceration closure is one of the most common procedures performed in the emergency department (ED). While sutures and staples have been the traditional wound closure device, topical skin adhesives (TSA) were introduced in the United States 20 years ago as a non-invasive alternative for simple, low-tension wounds. We determined which closure devices were used to close ED lacerations and explored patient and provider characteristics associated with choosing TSA. We also tested the hypothesis that use of TSA would be associated with shorter ED length of stay (LOS) than sutures/staples.We extracted demographic and clinical data on all patients with a laceration from the publicly available website of the National Hospital Ambulatory Medical Care Survey for the years 2012-2015. This database is provided by the National Center for Health Statistics of the CDC. Based on weighted sampling, national estimates are made for all ED visits in the US. We determined the association between patient characteristics (age, sex, insurance type, geographic location, laceration site, type of ED provider) and use of TSA. We also compared ED LOS between patients whose wounds were closed with TSA or sutures/staples using the t-test and a linear regression model.There were an estimated 540 million ED patient visits, and 26.1 million patients (4.8%) had at least one laceration. Of the 15.4 million patients with a single laceration, 9.2 million were closed with either sutures/staples (7.2 million), TSA (1.5 million), or both (0.5 million). Mean (SE) age was 30 (1) years, 63% were male and 42% were under age 18 years. Lacerations were on the upper extremity (42%), face (30%), lower extremity (14%) and scalp (8%). Of patients with a single laceration closed with either TSA or sutures/staples, use of TSA did not differ by age, sex, year, geographic location or wound site. ED LOS was significantly shorter in patients whose wounds were closed with TSA (101 ± 7 vs. 136 ± 4 min; P 0.001). After adjusting for potential confounding variables, use of TSA was associated with a 26 (95% CI 9-44) minute shorter ED LOS (P = 0.004) then sutures/staples.Topical skin adhesives are used in about 1 of 4 wound closures in the ED. Use of TSA did not differ based on demographic characteristics or wound site. Use of TSA is associated with a shorter ED LOS than sutures/staples.

Background A patient's vital signs are all inextricably interrelated, and together provide critical information regarding hemodynamic and physiological status. Yet, the precise relationship between body temperature (T) and heart rate (HR) in adults remains a fundamental gap in our knowledge. Methods We performed a retrospective secondary analysis of (1) electronic medical records from a large academic center (annual ED census of 110,000) and (2) the National Hospital Ambulatory Medical Care Survey (NHAMCS), a large CDC-sponsored weighted sample of U.S. EDs and our own large tertiary care ED, extracting demographic and clinical data including vital signs. Results We included 8715 local ED visits and approximately 123.3 million estimated national adult ED visits. Mean T was 36.9 °C, and 5.2% of patients had a T over 38 °C. Mean (SD) HR was 93.3 bpm, 28% had a HR over 100 bpm. Males had significantly lower HR than females (coefficient −1.6, 95%CI −2.4 to −0.8), while age was negatively associated with HR (coefficient −0.08, 95%CI −0.10 to −0.06). For national data, an increase of 1 °C in T corresponded to an increase in HR of 7.2 bpm (95%CI 6.2 to 8.3). After adjusting for age and gender, a 1 °C increase in T corresponded to a mean (95%CI) 10.4 (9.5–11.4) and 6.9 (5.9–7.8) increase in HR locally and nationally, respectively. Conclusions Among adult ED patients nationally, for every increase in T of 1 °C, the HR increases by approximately 7 bpm.

Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p 0.001) and COPD Only (p 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93).ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

Aim To evaluate whether portable chest radiography (CXR) scores are associated with coronavirus disease 2019 (COVID-19) status and various clinical outcomes. Materials and methods This retrospective study included 500 initial CXR from COVID-19-suspected patients. Each CXR was scored based on geographic extent and degree of opacity as indicators of disease severity. COVID-19 status and clinical outcomes including intensive care unit (ICU) admission, mechanical ventilation, mortality, length of hospitalisation, and duration on ventilator were collected. Multivariable logistic regression analysis was performed to evaluate the relationship between CXR scores and COVID-19 status, CXR scores and clinical outcomes, adjusted for code status, age, gender and co-morbidities. Results The interclass correlation coefficients amongst raters were 0.94 and 0.90 for the extent score and opacity score, respectively. CXR scores were significantly (p0.05). CXR scores were not associated with length of hospitalisation or duration on ventilation (p>0.05). Conclusions Initial CXR scores have prognostic value and are associated with COVID-19 positivity, ICU admission, and mechanical ventilation.

OBJECTIVE There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield. METHODS A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis. RESULTS 1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53). CONCLUSIONS There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.

Background Despite reported higher rates and worse outcomes due to COVID‐19 in certain racial and ethnic groups, much remains unknown. We explored the association between Hispanic ethnicity and outcomes in COVID‐19 patients in Long Island, New York. Methods We conducted a retrospective cohort study of 2,039 Hispanic and non‐Hispanic Caucasian patients testing positive for SARS‐CoV‐2 between March 7 and May 23, 2020, at a large suburban academic tertiary care hospital near New York City. We explored the association of ethnicity with need for intensive care unit (ICU), invasive mechanical ventilation (IMV), and mortality. Results Of all patients, 1,079 (53%) were non‐Hispanic Caucasians and 960 (47%) were Hispanic. Hispanic patients presented in higher numbers than expected for our catchment area. Compared with Caucasians, Hispanics were younger (45 years vs. 59 years), had fewer comorbidities (66% with no comorbidities vs. 40%), were less likely to have commercial insurance (35% vs. 59%), or were less likely to come from a nursing home (2% vs. 10%). In univariate comparisons, Hispanics were less likely to be admitted (37% vs. 59%) or to die (3% vs. 10%). Age, shortness of breath, congestive heart failure (CHF), coronary artery disease (CAD), hypoxemia, and presentation from nursing homes were associated with admission. Male sex and hypoxemia were associated with ICU admission. Male sex, chronic obstructive pulmonary disease, and hypoxemia were associated with IMV. Male sex, CHF, CAD, and hypoxemia were associated with mortality. After other factors were adjusted for, Hispanics were less likely to be admitted (odds ratio = 0.62, 95% confidence interval = 0.52 to 0.92) but Hispanic ethnicity was not associated with ICU admission, IMV, or mortality. Conclusions Hispanics presented at higher rates than average for our population but outcomes among Hispanic patients with COVID‐19 were similar to those of Caucasian patients.

Objective To examine the processes and barriers involved in providing postdischarge stroke care. Design Prospective study of discharge planners’ (DP) and physical therapists’ (PT) interpretation of factors contributing to patients’ discharge destination. Setting Twenty-three hospitals in the northeastern United States. Participants After exclusions, data on patients (N=427) hospitalized with a primary diagnosis of stroke between May 2015 and November 2016 were examined. Of the patients, 45% were women, and the median age was 71 years. DPs and PTs caring for these patients were queried regarding the selection of discharge destination. Interventions None. Main Outcome Measures Comparison of actual discharge destination for stroke patients with the destinations recommended by their DPs and PTs. Results In total, 184 patients (43.1%) were discharged home, 146 (34.2%) to an inpatient rehabilitation facility, 94 (22.0%) to a skilled nursing facility, and 3 (0.7%) to a long-term acute care hospital. DPs and PTs agreed on the recommended discharge destination in 355 (83.1%) cases. The actual discharge destination matched the DP and PT recommended discharge destination in 92.5% of these cases. In 23 cases (6.5%), the patient was discharged to a less intensive setting than recommended by both respondents. In 4 cases (1.1%), the patient was discharged to a more intensive level of care. In 2 cases (0.6%), the patient was discharged to a long-term acute care hospital rather than an inpatient rehabilitation facility as recommended. Patient or family preference was cited by at least 1 respondent for the discrepancy in discharge destination for 13 patients (3.1%); insurance barriers were cited for 9 patients (2.3%). Conclusions Most stroke survivors in the northeast United States are discharged to the recommended postacute care destination based on the consensus of DP and PT opinions. Further research is needed to guide postacute care service selection.

Study objective Most coronavirus disease 2019 (COVID-19) reports have focused on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients. However, at initial presentation, most patients’ viral status is unknown. Determination of factors that predict initial and subsequent need for ICU and invasive mechanical ventilation is critical for resource planning and allocation. We describe our experience with 4,404 persons under investigation and explore predictors of ICU care and invasive mechanical ventilation at a New York COVID-19 epicenter. Methods We conducted a retrospective cohort study of all persons under investigation and presenting to a large academic medical center emergency department (ED) in New York State with symptoms suggestive of COVID-19. The association between patient predictor variables and SARS-CoV-2 status, ICU admission, invasive mechanical ventilation, and mortality was explored with univariate and multivariate analyses. Results Between March 12 and April 14, 2020, we treated 4,404 persons under investigation for COVID-19 infection, of whom 68% were discharged home, 29% were admitted to a regular floor, and 3% to an ICU. One thousand six hundred fifty-one of 3,369 patients tested have had SARS-CoV-2–positive results to date. Of patients with regular floor admissions, 13% were subsequently upgraded to the ICU after a median of 62 hours (interquartile range 28 to 106 hours). Fifty patients required invasive mechanical ventilation in the ED, 4 required out-of-hospital invasive mechanical ventilation, and another 167 subsequently required invasive mechanical ventilation in a median of 60 hours (interquartile range 26 to 99) hours after admission. Testing positive for SARS-CoV-2 and lower oxygen saturations were associated with need for ICU and invasive mechanical ventilation, and with death. High respiratory rates were associated with the need for ICU care. Conclusion Persons under investigation for COVID-19 infection contribute significantly to the health care burden beyond those ruling in for SARS-CoV-2. For every 100 admitted persons under investigation, 9 will require ICU stay, invasive mechanical ventilation, or both on arrival and another 12 within 2 to 3 days of hospital admission, especially persons under investigation with lower oxygen saturations and positive SARS-CoV-2 swab results. This information should help hospitals manage the pandemic efficiently.

This study aimed to develop risk scores based on clinical characteristics at presentation to predict intensive care unit (ICU) admission and mortality in COVID-19 patients. 641 hospitalized patients with laboratory-confirmed COVID-19 were selected from 4997 persons under investigation. We performed a retrospective review of medical records of demographics, comorbidities and laboratory tests at the initial presentation. Primary outcomes were ICU admission and death. Logistic regression was used to identify independent clinical variables predicting the two outcomes. The model was validated by splitting the data into 70% for training and 30% for testing. Performance accuracy was evaluated using area under the curve (AUC) of the receiver operating characteristic analysis (ROC). Five significant variables predicting ICU admission were lactate dehydrogenase, procalcitonin, pulse oxygen saturation, smoking history, and lymphocyte count. Seven significant variables predicting mortality were heart failure, procalcitonin, lactate dehydrogenase, chronic obstructive pulmonary disease, pulse oxygen saturation, heart rate, and age. The mortality group uniquely contained cardiopulmonary variables. The risk score model yielded good accuracy with an AUC of 0.74 ([95% CI, 0.63–0.85], p = 0.001) for predicting ICU admission and 0.83 ([95% CI, 0.73–0.92], p

Background Core laboratory testing may increase length of stay and delay care. Objectives We compared length of emergency department (ED) care in patients receiving point-of-care testing (POCT) at triage vs. traditional core laboratory testing. Methods We conducted a prospective, case-controlled trial of adult patients with prespecified conditions requiring laboratory testing and had POCT performed by a nurse after triage for: a basic metabolic panel, troponin I, lactate, INR (i-STAT System), urinalysis (Beckman Coulter Icon), or urine pregnancy test. Study patients were matched with controls based on clinical condition, gender, age, and time to be seen. Groups were compared with Wilcoxon rank–sum or Fisher's exact tests. Results We matched 52 POCT study patients with 52 controls. Groups were similar in age, gender, clinical condition, time to be seen by a physician (3.3 h, 95% confidence interval [CI] 2.2–4.4, vs. 3.1 h, 95% CI 2.2–4.5 h, in POCT and control patients, respectively; p = 0.84), use of imaging, and disposition. Of 52 study patients, 3 (5.8%, 95% CI 2.0–15.9) were immediately transferred to the critical care area to be urgently seen by an emergency physician. POCT patients had a significantly shorter median (interquartile range [IQR]) ED care time than matched controls (7.6, 95% CI 5.1–9.5 vs. 8.5, 6.2–11.3 h, respectively; p = 0.015). Median [IQR] ED length of stay was similar in study patients and controls (9.6, 95% CI 7.9–14.5 vs. 12.5, 8.2–21.2 h, respectively; p = 0.15). Conclusions Among stable adult patients presenting to the ED with one of the prespecified conditions, early POCT at triage, compared with traditional core laboratory testing after evaluation by an ED provider, reduced ED care time by approximately 1 h.

Background Point-of-care (POC) testing reduces laboratory turn-around having the potential to improve timely diagnosis and management. We compared the accuracy of nurse performed POC and core laboratory testing and determined whether deviations between the two were clinically meaningful. Methods We performed a prospective, observational study on a convenience sample of 50 critical care ED patients in whom a POC chemistry and hematocrit was ordered. Blood samples were divided into 2 aliquots; one sample was tested by the treating nurse using a handheld POC device and the other sample was tested in the core laboratory. Paired comparisons of test results were performed using Pearson's correlation coefficients, Lin concordance coefficients, and Bland Altman plots. Results Mean patient age was 67, 50% were male, 82% were admitted. Pearson's correlation and Lin concordance coefficients were excellent (0.84–1.00) for all 8 analytes. Mean (95%CI) paired differences between POC and core laboratory measurements were Na+ 0.30 (− 0.22 to 0.82) mmol/L, K+ − 0.12 (− 0.14 to - 0.09) mmol/L, Cl− 2.10 (1.41 to 2.78) mmol/L, TCO2–1.68 (− 2.06 to − 1.30) mmol/L, glucose 2.46 (1.46 to 3.46) mg/dL, BUN, 1.69 (0.95 to 2.42) mg/dL, creatinine 0.13 (0.08 to 0.17) mg/dL, and hematocrit − 0.39 (− 0.93 to 0.15) %. In 3 of 400 measurements, the difference between POC and core lab exceeded the maximal clinically acceptable deviation based on physician surveys. Conclusions Bedside POC by ED nurses is reliable and accurate and does not deviate significantly from core laboratory testing by trained technicians.

Study objective Both end tidal CO2 (ETCO2) and cerebral oxygen saturations (rSO2) have been studied to determine their ability to monitor the effectiveness of CPR and predict return of spontaneous circulation (ROSC). We compared the accuracy of ETCO2 and rSO2 at predicting ROSC in ED patients with out-of-hospital cardiac arrest (OHCA). Methods We performed a prospective, observational study of adult ED patients presenting in cardiac arrest. We collected demographic and clinical data including age, gender, presenting rhythm, rSO2, and ETCO2. We used receiver operating characteristic curves to compare how well rSO2 and ETCO2 predicted ROSC. Results 225 patients presented to the ED with cardiac arrest between 10/11 and 10/14 of which 100 had both rSO2 and ETCO2 measurements. Thirty three patients (33%) had sustained ROSC, only 2 survived to discharge. The AUCs for rSO2 and ETCO2 were similar (0.69 [95% CI, 0.59–0.80] and 0.77 [95% CI, 0.68–0.86], respectively), however, rSO2 and ETCO2 were poorly correlated (0.12, 95% CI, − 0.08–0.31). The optimal cutoffs for rSO2 and ETCO2 were 50% and 20 mm Hg respectively. At these cutoffs, ETCO2 was more sensitive (100%, 95% CI 87–100 vs. 48%, 31–66) but rSO2 was more specific (85%, 95% CI, 74–92 vs. 45%, 33–57). Conclusions While poorly correlated, rSO2 and ETCO2 have similar diagnostic characteristics. ETCO2 is more sensitive and rSO2 is more specific at predicting ROSC in OHCA.

A number or risk assessment tools are used in trauma victims. Because of its simplicity, we examined the ability of the recently described quick Sequential Organ Failure Assessment Score (qSOFA) to predict outcomes in blunt trauma patients presenting to the Emergency Department.We queried the trauma registry at a Level 1 Trauma Center for all adult blunt trauma admissions between 1/1/10 and 9/30/15. qSOFA scores were the sum of binary scores for 3 variables (RR ≥ 22, SBP≤100 mmHg, and GCS≤13).There were 7064 admissions (5664 admissions had qSOFA = 0, 1164 had qSOFA = 1, 223 had qSOFA = 2, and 13 had qSOFA = 3). Higher qSOFA scores were associated with greater injury severity, increased ICU admission, and higher complication rates. qSOFA scores were associated with in-hospital mortality (1.7% with qSOFA = 0; 8.7% with qSOFA = 1; 22.4% with qSOFA = 2; 23.1% with qSOFA = 3; p 0.001). On multivariate analysis, qSOFA score was an independent predictor of mortality.qSOFA scores are directly associated with adverse outcomes in blunt trauma victims.

Objective Disturbances in potassium (K) levels are relatively common and may be associated with significant morbidity and mortality; however, treatments vary. Our purpose was to determine the incidence, treatments, and outcomes associated with hyperkalemia and hypokalemia in emergency department (ED) patients. Methods We performed a structured, retrospective review of electronic medical records of consecutive adult ED patients with K measured while in the ED. Demographic, clinical, and laboratory data as well as treatments, disposition, and in-hospital complications were collected. Univariate and multivariate analyses, presented as adjusted odds ratios, were used to compare outcomes by K levels. Results Of 100,260 visits in 2014, an ED K level was ordered in 48,827 (49%). A total of 1,738 patients (3.6%) were excluded because of sample hemolysis. The K was low (5.0 mEq/L) in 3.6% of patients. Patients with hyperkalemia were older (64 vs. 49 years, P6 mEq/L. Conclusion Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Study objectives Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. Methods We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ 2 tests and C statistics. Results The patients' median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92–0.97). Conclusions Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

Study objective The Quick Sequential Organ Failure Assessment (qSOFA) score (composed of respiratory rate ≥22 breaths/min, systolic blood pressure ≤100 mm Hg, and altered mental status) may identify patients with infection who are at risk of complications. We determined the association between qSOFA scores and outcomes in adult emergency department (ED) patients with and without suspected infection. Methods We performed a single-site, retrospective review of adult ED patients between January 2014 and March 2015. Patients triaged to fast-track, dentistry, psychiatry, and labor and delivery were excluded. qSOFA scores were calculated with simultaneous vital signs and Modified Early Warning System scores. Patients receiving intravenous antibiotics were presumed to have suspected infection. Univariate and multivariate analyses were performed to explore the association between qSOFA scores and inpatient mortality, admission, and length of stay. Receiver operating characteristics curve analysis and c statistics were also calculated for ICU admission and mortality. Results We included 22,530 patients. Mean age was 54 years (SD 21 years), 53% were women, 45% were admitted, and mortality rate was 1.6%. qSOFA scores were associated with mortality (0 [0.6%], 1 [2.8%], 2 [12.8%], and 3 [25.0%]), ICU admission (0 [5.1%], 1 [10.5%], 2 [20.8%], and 3 [27.4%]), and hospital length of stay (0 [123 hours], 1 [163 hours], 2 [225 hours], and 3 [237 hours]). Adjusted rates were also associated with qSOFA. The c statistics for mortality in patients with and without suspected infection were similarly high (0.75 [95% confidence interval 0.71 to 0.78) and 0.70 (95% confidence interval 0.65 to 0.74), respectively. Conclusion qSOFA scores were associated with inpatient mortality, admission, ICU admission, and hospital length of stay in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.

Recent advances in time-sensitive mechanical thrombectomy for the treatment of emergent large vessel occlusion (ELVO) have changed the role of prehospital providers from simply identifying a stroke to identifying the likely presence of ELVO. No one method for identifying ELVO in the field has been demonstrated to be superior. We sought to describe how this might be best accomplished using the Los Angeles Motor Scale (LAMS) in concert with other physical exam findings by paramedics and emergency medical technicians (EMTs). We had paramedics and EMTs examine patients with suspected stroke in the hospital. We compared their exams to the standard neurologist exams and to the results of angiography. We performed multiple analyses to identify the exam elements that would best identify large vessel occlusions. Using LAMS with a threshold score of 4, sensitivity for stroke and ELVO, respectively, was 27% (95% CI 20-36%) and 42% (95% CI 30-55%). When a LAMS of 3 was used in concert with speech abnormality, sensitivity improved to 36% (95% CI 28-45%) and 61% (95% CI 48-73%). Specificity of this model was 70%, (95% CI 64-75%). Most striking was the negative predictive value of this model for ELVO: 90% (95% CI 85-93%) The LAMS or LAMS plus speech can be used to decrease the number of missed large vessel occlusions and to route suspected large vessel occlusions to thrombectomy-capable centers. Other, more complicated scales may have little additional benefit. This derivation data set is the first to use paramedics and EMTs as examiners prospectively and supports prehospital protocol change underway in New York City.

Introduction: The process of determining stroke survivor’s post-acute care is not well understood. This study sought to examine the factors influencing these decisions and barriers to obtaining care. Methods: 23 hospitals in the northeastern US each contributed data on approximately 20 consecutive acute stroke patients. Discharge planners (DP) and physical therapists (PT) involved in the care of each patient were queried regarding the selection of discharge destination and any barriers encountered. Results: Data was analyzed for 427 stroke patients hospitalized from May 2015 - November 2016; 45% of the patients were female, the mean age was 71 + 15 and primary insurance was Medicare (50.8%), Medicaid (4.9%), Managed Care/Commercial (21.5%) or other/uninsured (3.3%); no response/unavailable (19.4%). One hundred and eighty-four patients (43.1%) were discharged directly home, 146 (34.2%) were discharged to an Inpatient Rehabilitation Facility, 94 (22.0%) were discharged to a Skilled Nursing Facility, and 3(0.7%) to a Long Term Acute Care Hospital. DPs and PTs agreed regarding preferred discharge destination in 355 (83.1%) of cases. The actual discharge destination matched the preferred discharge destination in 92.5% of these cases. There were 23 cases (6.5%) where the patient was discharged to a less intensive setting than preferred by both respondents, and in 8 (2.3%) insurance barriers were cited by at least one respondent as the reason for the discrepancy in discharge destination. In most of the remaining cases the discrepancy was accounted for by “patient/family preference”. Conclusions: Most stroke survivors in the Northeast are discharged to the “most appropriate” post-acute facility based on the opinion of their discharge planners and physical therapists. Most patients discharged to less intensive settings than preferred by their DPs and PTs, were attributed to patient/family preference, with only a small minority discharged to another type of setting based on insurance or other limitations. This supports the hypothesis that local referral preferences may be a larger driver of the variation in the utilization of post-acute care rather than insurance or other barriers. Further research is needed to clarify optimal care for this population.

Several scoring systems, such as the Baux score, help predict outcomes in burn patients. The quick Sequential Organ Failure Assessment (qSOFA) score (composed of a respiratory rate of 22/min or greater, systolic blood pressure of 100 mmHg or less, and altered mental status) is a new bedside index proposed to help identify patients with suspected infection at risk of complications. We hypothesized that qSOFA scores would be associated with in-hospital mortality, ICU admission, and length of stay (LOS) in patients with burns. We performed a retrospective review of all burn patients admitted between January 2010-March 2017 at an academic, suburban, hospital with a regional burn center. qSOFA scores were calculated as 1 point each for GCS15, RR≥22, and SBP≤100. A qSOFA value of2 was considered high risk. Revised Baux (rBaux) scores were calculated as age +%TBSA burned +17 (if inhalation injury). A rBaux score140 was considered high risk. Univariate, multivariate and receiver operating characteristics analyses were performed to compare qSOFA and rBaux scores. There were 1039 burn admissions during the study period. Mean age was 30 ± 24 years, 66% were male. Mean TBSA was 10 ± 12%, mean injury severity score was 5 ± 8. Mean hospital LOS was 8 ± 24 days, 22 patients (2.1%) died. qSOFA scores were associated with mortality and ICU admission. Of all patients, 80 were high risk by qSOFA and 7 by Baux scores. ROC characteristics of qSOFA and Baux scores for predicting death were sensitivity 36% vs. 32%, specificity 94% vs. 100%, PPV 13% vs. 100%, and NPV 98% vs. 99% respectively. The AUC for qSOFA (0.68 [95% CI, 0.54-0.81]) was lower than for Baux (0.99 [95%CI, 0.99-1.00]). Youden's index identified an optimal cutoff of 85 on the Baux score yielding sensitivity 100%, specificity 94%, PPV 27%, and NPV 100% for mortality. Our results indicate that while qSOFA scores were associated with outcomes, a rBaux score had greater predictive value. The optimal rBaux score for predicting all mortality and ICU admission was 85.

Background Public awareness of the opioid epidemic is increasing nationally, emphasizing the need to develop methods to reduce opioid use. We determined patient preference for analgesics before and after a brief educational intervention informing them of the risks and benefits of opioids versus non-steroidal anti-inflammatory drugs (NSAID's). We hypothesized 50% of patients would prefer opioids pre-intervention and that this would be reduced by the intervention by at least 15%. Methods Study Design—Before and after study. Setting—Suburban ED with annual census of 110,000. Patients—English-speaking adult ED patients with acute musculoskeletal pain. Interventions—An anonymous survey was administered by an investigator not involved in the patient's clinical care prior to physician evaluation, before and after a video describing the risks and benefits of opioids versus NSAID's. Patients were asked if they desired analgesics. Data Analysis—Descriptive statistics were used to summarize the data. Univariate analysis and logistic regression were used to predict patient demographics and pain characteristics associated with desire for analgesics. Results Of all 94 patients, 48 (51% [95% CI 41–62%]) desired an analgesic pre-intervention. Of these 48 patients, 10 (11% [5–19%]) specifically preferred an opioid. Of the 10 patients who preferred an opioid pre-intervention, one had no preference for analgesic post-intervention. Conclusions Many adult ED patients with acute musculoskeletal pain do not desire any analgesics and few specifically prefer opioids. This knowledge can prove helpful to ED physicians across the country in discussing pain management options with patients as we attempt to combat the opioid epidemic.

Background Nausea and vomiting are common, but prevalence of antiemetic use in ED patients is unknown. Objectives We determined the use of antiemetics in emergency department (ED) patients presenting with nausea and vomiting (NV). Methods We conducted a retrospective chart review of ED patients presenting to a local ED with NV and analyzed data from the National Hospital Ambulatory Care Survey for similar patients to determine the frequency of administration of antiemetics in the ED. Results Of 3876 patients presenting to a local ED with NV in 2014, 2637 (68% [95% confidence interval (CI) 67–69%]) received an antiemetic. Of an estimated 11.3 million U.S. ED visits for NV in 2011 (the latest year available), antiemetics were prescribed in 56% (95% CI 53–59%). Females, older patients, and those with vomiting were more likely to receive antiemetics. Use of antiemetics was associated with reduced admissions in the single institution (odds ratio [OR] 0.62, 95% CI 0.52–0.74), but not in the national database (OR 1.08, 95% CI 0.74–1.60). Conclusions Many patients presenting with NV do not receive antiemetics while in the ED. Effort should be made to further study and reduce the phenomenon of undertreatment of nausea or vomiting, coined “oligoantiemesis.”

In order to be useful, animal models should be reproducible and consistent regardless of sampling bias, investigator creating burn, and burn location. We determined the variability in burn depth based on biopsy location, burn location and investigator in a porcine model of partial thickness burns.24 partial thickness burns (2.5 cm by 2.5 cm each) were created on the backs of 2 anesthetized pigs by 2 investigators (one experienced, one inexperienced) using a previously validated model. In one of the pigs, the necrotic epidermis covering each burn was removed. Five full thickness 4mm punch biopsies were obtained 1h after injury from the four corners and center of the burns and stained with Hematoxylin and Eosin and Masson's trichrome for determination of burn depth by a board certified dermatopathologist blinded to burn location and investigator. Comparisons of burn depth by biopsy location, burn location and investigator were performed with t-tests and ANOVA as appropriate.The mean (SD) depth of injury to blood vessels (the main determinant of burn progression) in debrided and non-debrided pigs pooled together was 1.8 (0.3)mm, which included 75% of the dermal depth. Non-debrided burns were 0.24 mm deeper than debrided burns (P0.001). Burn depth increased marginally from cephalic to caudal in non-debrided burns, but showed no statistical differences for these locations, in debrided burns. Additionally, there were also no statistical differences in burn depths from midline to lateral in either of these burn types. Burn depth was similar for both investigators and among biopsy locations.Burn depth was greater for caudal locations in non-debrided burns and overall non-debrided burns were deeper than debrided burns. However, burn depth did not differ based on investigator, biopsy site, and medial-lateral location.

Burn therapies should focus on achieving outcomes that are most important to patients. The authors wanted to discover which outcomes newly burned patients would anticipate as most important to them and explored the association between demographic/burn characteristics and patient preferences. The authors surveyed 753 of 776 patients seen by our burn service from 2008 to 2013 during the initial encounter. Patients were asked to rate the anticipated importance of several burn outcomes including cosmetic appearance, resumption of normal function, and the lack of pain/itching on a four-item Likert scale (not important, somewhat important, important, and extremely important). The association between demographic and burn characteristics with patient's views on the importance of various outcomes was explored with χ and nonparametric tests. Patient mean (SD) age was 30 (22) years, 58% were males, 69% were white. Overall, function was extremely important to 96% of patients, lack of pain/itching was extremely important to 85% of patients, and cosmesis was extremely important to 59% of patients. Cosmesis was extremely important to more females than males (69 vs 52%; P < .001) and the mean age of patients in whom cosmesis was extremely important was lower than those in whom it was not (25 vs 40; P < .001). Cosmesis was more commonly extremely important in patients with head/neck than extremity burns (67 vs 57%; P < .001). Levels of importance for function and lack of pain/itching did not differ by gender, age, TBSA, or burn location. Thus, return to normal function and lack of pain and itching appear to be more commonly very important to burn patient than the cosmetic appearance of their burns. Cosmesis was of greater importance to younger patients, female patients, and those with head/neck burns.

Background Previously, analgesics were avoided in suspected appendicitis to avoid masking the diagnosis. We determined use of analgesia in patients with appendicitis to determine recent trends over time and explore predictors of use of analgesia. Methods A retrospective review of the National Hospital Ambulatory Medical Care Survey 2006–2010 was conducted including emergency department (ED) patients with acute appendicitis ( ICD-9-CM 540.xx). The association between demographic and clinical information with ED visit prescription of analgesics/opioids was determined using univariate ( χ 2 ) and multivariate (logistic regression) analyses. Results There were an estimated 763000 ED patient visits for acute appendicitis from 2006 to 2010. Mean age was 32, 74% were under age 19, 69% were male. Sixty-four percent of patients received any analgesia in the ED and 58% received an opioid; use of analgesics did not change over time. Of all patients, 68% had computed tomographic (CT) imaging. There was a positive trend in analgesic use with increasing pain (27% for no pain to 71% for severe pain, P = .08); a similar trend was seen for opioids but was not significant ( P = .12). Analgesic use was lower for elderly (age >65) patients (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.01-0.56) and private insurance (OR 0.14, 95% CI 0.05-0.43), and higher for patients with CT scans (OR 3.73, 95% CI 1.61-8.66). Pain severity was not associated with administration of analgesics after controlling for other factors. Conclusions Use of analgesia and opioids analgesia has remained stable over time. Factors associated with prescription of any analgesia and opioids were older age and payment source. Use of CT was associated with prescription of analgesics.

Introduction Prior studies comparing scalds and contact burns rarely address the affect of burn etiology on burn depth. However, it is commonly believed that scalds tend to heal faster than similarly sized contact and flame burns. As a result, expectant therapy is often preferred after scald injuries. We compared the percentages of full-thickness burns based on burn etiology controlling for burn size, location and patient age. We hypothesized that the percentage of full thickness burns would be lower after scalds compared with contact and flame burns. Methods We performed a retrospective chart review of a prospectively collected burn registry of all patients admitted to a regional burn center between 2000–2010. Data collection included patient and burn characteristics including age, gender, body location, and burn etiology. We compared the percentages of full thickness burns among scald, contact and flame burns using Chi-square tests. Stepwise logistic regression was used to adjust for age, location, and burn size. Results There were 1038 patients in the study with either scald (n=537, 52%), fire/flame (n=434, 42%) or contact (n=67, 6%) burn. Mean (SD) age was 29 (25); 75% were male. Mean (SD) total body surface area (TBSA) was 11 (13)%. Mean (SD) length of stay was 10 (18) days. The percentages of full thickness burns by etiology were scalds 13.1%, fire/flame 34%, and contact burns 45% (P< 0.001). Patients with scalds were younger (22+/-24) than patients with contacts (32+/-28) and fire/flame (38+/-22) burns. Multivariate analysis for predicting full thickness burns found that compared with contact burns, scalds were less likely full thickness (OR 0.23, 95%CI 0.11–0.48) while fire/flame burns were as likely to be full thickness (OR 0.54, 95%CI 0.26–1.15). TBSA and age were also associated with full thickness burns (OR 1.06, 95%CI 1.04–1.09 and OR 1.015, 95%CI 1.007–1.024, respectively). Burns on the head and neck were less likely to be full thickness (OR 0.30, 95%CI, 0.11–0.82). Conclusions Scald burns are significantly less likely to be full thickness than contact or fire/flame burns. Applicability of Research to Practice Based on these results, expectant therapy may be more appropriate for scalds than contact or fire/flame burns.

Background: Studies have documented the effectiveness of endovascular therapies in large vessel occlusions (LVO). Since not all primary stroke centers are capable of delivering endovascular care, emergency medical services are now tasked with routing such patients who have large vessel occlusions to facilities capable of delivering such therapies. There are patient specific and and emergency medical system issues to a decision to bypass a local primary stroke center in favor of transport to an comprehensive center. Few of the LVO identification tools have been validated by paramedics. We sought to describe the utility of the Los Angeles Motor Score (LAMS) and of other physical findings for predicting the presence of a LVO in a population of stroke code patients examined by paramedics and EMTs. Methods: We analyzed a convenience sample of stroke code patients presenting to a tertiary care center ED. Paramedics examined patients using the LAMS. Paramedics were also asked to assess for problems including leg weakness, visual disturbances, altered level of consciousness, and language abnormalities (dysarthria, aphasia). We calculated operating characteristics of a LAMS score of ≥ 4 and of a modification of the LAMS to include speech disturbance, and performed a stepwise logistical regression on the other potential physical exam elements that might predict large vessel occlusion. Results: A total of 332 subjects mean age 68 (±SD17), 53% female were examined by paramedics. One hundred forty (42%) had a stroke, and of these 71 (21%) had an LVO. A LAMS ≥ 4 identified stroke and large vessel occlusions with sensitivity of 28% and 38% and specificity of 95% and 92% respectively. Using LAMS of 1 to 3 with an abnormal speech test, 12 additional strokes and 8 LVOs were identified with resultant sensitivity and specificity of 36% and 94% and 49% and 89% for stroke and LVO respectively. Conclusion: Performed by paramedics and EMTs in an enriched stroke code population, the LAMS score can be used to identify LVOs with high specificity. More importantly, use of the modified LAMS results in an NPV of 87% with a PPV of 56%. This suggests that application of the modified rule would capture many cases of LVO while transporting few patients longer distances unnecessarily.