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A high incidence of honey oil and methamphetamine production has led to an increase in burn victims presenting to this regional burn center in California. This study aims to compare patient outcomes resulting from burn injuries associated with honey oil and methamphetamine production. This is a retrospective cohort study using the regional burn registry to identify patients with burn injuries related to honey oil production or methamphetamine purification explosions from January 1, 2008 to December 31, 2017. Patient demographics and clinical outcomes data were abstracted from the burn registry and medical records. A total of 91 patients were included in the final analysis and 59.3% (n = 54) were related to honey oil injury. There was no statistically significant difference between honey oil and methamphetamine burn injuries in regard to clinical outcomes, including mortality (1.9% vs 8.1%, P = .1588), third-degree burn (47.2% vs 59.5%, P = .2508), mechanical ventilator usage (50% vs 69.4%, P = .0714), median hospital length of stay (LOS; 10 vs 11 days, P = .5308), ICU LOS (10 vs 11 days, P = .1903), total burn surface area (26.5% vs 28.3%, P = .8313), and hospital charge (median of US$85,561 vs US$139,028, P = .7215). Honey oil burn injuries are associated with similar hospital LOS, similar ICU LOS, similar total burn surface area, and present a costly public health concern. With the recent legalization of marijuana in California, commercial production of honey oil in addition to increasing education about the risks of illicit honey oil production may alleviate associated risks.

Introduction Telemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients’ perception of telemedicine in an urban ED. Methods A survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients’ perspective. Results A total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p

Background This study investigates the impact of methamphetamine use on trauma patient outcomes. Methods This retrospective study analyzed patients between 18 and 55 years old presenting to a single trauma center in San Bernardino County, CA who sustained traumatic injury during the 10-year study period (January 1st, 2005 to December 31st, 2015). Routine serum ethanol levels and urine drug screens (UDS) were completed on all trauma patients. Exclusion criteria included patients with an elevated serum ethanol level (> 0 mg/dL). Those who screened positive on UDS for only methamphetamine and negative for cocaine and cannabis (MA(+)) were compared to those with a triple negative UDS for methamphetamine, cocaine, and cannabis (MA(−)). The primary outcome studied was the impact of a methamphetamine positive drug screen on hospital mortality. Secondary outcomes included length of stay (LOS), heart rate, systolic and diastolic blood pressure (SBP and DBP, respectively), and total amount of blood products utilized during hospitalization. To analyze the effect of methamphetamine, age, gender, injury severity score, and mechanism of injury (blunt vs. penetrating) were matched between MA(−) and MA(+) through a propensity matching algorithm. Results After exclusion, 2538 patients were included in the final analysis; 449 were patients in the MA(+) group and 2089 patients in the MA(−) group. A selection of 449 MA(−) patients were matched with the MA(+) group based on age, gender, injury severity score, and mechanism of injury. This led to a final sample size of 898 patients with 449 patients in each group. No statistically significant change was observed in hospital mortality. Notably, a methamphetamine positive drug screen was associated with a longer LOS (median of 4 vs. 3 days in MA(+) and MA(−), respectively, p

Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock. Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma. Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0). Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock.

Introduction Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient's acuity level to determine the need to transport to an ED. Methods We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients' acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs' evaluations of patient's acuity level was compared using Chi-square test. Results We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics' and EPs' assessment on the same cohort of patients. Conclusion There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported.

Author(s): Neeki, Michael M.; Dong, Fanglong; Toy, Jake; Vaezazizi, Reza; Powell, Joe; Wong, David; Mousselli, Michael; Rabiei, Massoud; Jabourian, Alex; Niknafs, Nichole; Burgett-Moreno, Michelle; Vara, Richard; Kissel, Shanna; Luo-Owen, Xian; O'Bosky, Karen R.; Ludi, Daniel; Sporer, Karl; Pennington, Troy; Lee, Tommy; Borger, Rodney; Kwong, Eugene | Abstract: Introduction: Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock. Methods: The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration. Results: We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS g15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed. Conclusion: Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.

Introduction: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in grossmorbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis(LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. Thisstudy analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed tohave cellulitis, as well as the capability to differentiate cellulitis from NF. Methods: This was a 10-year retrospective chart-review study that included emergency department (ED)patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from0-13 for each patient with all pertinent laboratory values. Three categories were developed per the originalLRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINECscore 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence ofa C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC scorewas 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the“low risk” group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the“high risk” group. These patients missing CRP values were added to these respective groups. Results: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) weremoderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patientswithout CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, atotal of 47 patients were further classified based on LRINEC score without a CRP value. More than half of theNF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to performbetter in the diabetes population than in the non-diabetes population. Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiationbetween cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive ratewhen determining NF risk stratification in confirmed cases of celulitis and a high false negative rate in casesof confirmed NF.

Introduction: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols. Methods: This is an ongoing multi-centered, prospective, observational cohort study with a retrospective chart-review comparison. Trauma patients identified in the prehospital setting with signs of hemorrhagic shock by first responders were administered one gram of TXA followed by an optional second one-gram dose upon arrival to the hospital, if the patient still met inclusion criteria. Patients administered TXA make up the prehospital intervention group. Control group patients met the same inclusion criteria as TXA candidates and were matched with the prehospital intervention patients based on mechanism of injury, injury severity score, and age. The primary outcomes were mortality, measured at 24 hours, 48 hours, and 28 days. Secondary outcomes measured included the total blood products transfused and any known adverse events associated with TXA administration. Results: We included 128 patients in the prehospital intervention group and 125 in the control group. Although not statistically significant, the prehospital intervention group trended toward a lower 24-hour mortality rate (3.9% vs 7.2% for intervention and control, respectively, p=0.25), 48-hour mortality rate (6.3% vs 7.2% for intervention and control, respectively, p=0.76), and 28-day mortality rate (6.3% vs 10.4% for intervention and control, respectively, p=0.23). There was no significant difference observed in known adverse events associated with TXA administration in the prehospital intervention group and control group. A reduction in total blood product usage was observed following the administration of TXA (control: 6.95 units; intervention: 4.09 units; p=0.01). Conclusion: Preliminary evidence from the Cal-PAT study suggests that TXA administration may be safe in the prehospital setting with no significant change in adverse events observed and an associated decreased use of blood products in cases of trauma-induced hemorrhagic shock. Given the current sample size, a statistically significant decrease in mortality was not observed. Additionally, this study demonstrates that it may be feasible for paramedics to identify and safely administer TXA in the prehospital setting.

Methamphetamine is one of the most commonly abused illegal drugs in the United States. Health care providers are commonly faced with medical illness caused by methamphetamine. This study investigates the impact of methamphetamine use on the severity of cardiomyopathy and heart failure in young adults. This retrospective study analyzed patients seen at Arrowhead Regional Medical Center from 2008 to 2012. Patients were between 18 and 50 years old. All patients had a discharge diagnosis of cardiomyopathy or heart failure. The severity of disease was quantified by left ventricular systolic dysfunction: heart failure with preserved ejection fraction to mildly reduced if ejection fraction was >40% and moderate to severely depressed if ejection fraction was ≤40%. Methamphetamine abuse was determined by a positive urine drug screen or per documented history. Of the 590 patients, 223 (37.8%) had a history of methamphetamine use. More than half the population was men (n = 389, 62.3%); 41% was Hispanic (n = 243), 25.8% was Caucasian (n = 152), and 27.8% was African-American (n = 164); 60.9% were in the age range of 41 to 50 years (n = 359). Patients with a history of methamphetamine use had increased odds (odds ratio = 1.80, 95% confidence interval 1.27 to 2.57) of having a moderately or severely reduced ejection fraction. Additionally, men were more likely (odds ratio 3.13, 95% confidence interval 2.14 to 4.56) to have worse left ventricular systolic dysfunction. In conclusion, methamphetamine use was associated with an increased severity of cardiomyopathy in young adults.

Study objective: Although adjunctive intravenous bicarbonate therapy is commonly recommended for children with severe diabetic ketoacidosis (DKA), no studies assessing clinical outcome with this therapy have ever been performed. Our objective was to determine whether bicarbonate therapy influenced outcome for pediatric DKA. Methods: The study was a retrospective consecutive case series of 147 admissions for severe DKA (initial pH ≤7.15 and glucose concentration ≥300 mg/dL [16.7 mmol/L]) in 106 children during a 16-year period at a tertiary university medical center. Descriptive statistics were applied to the 147 admissions. The first patient admitted with DKA was then selected for each of the 106 children, and clinical and laboratory data were compared between subjects who did and did not receive bicarbonate. Multivariate and matched pair analyses were performed to control potentially confounding variables. Results: Fifty-seven of the 147 patients admitted with DKA (39%) were successfully treated without bicarbonate, including 9 with a pH of 7.00 or less and one with a pH of 6.73. The frequency of complications was comparable between bicarbonate and nonbicarbonate groups (4% versus 2%, P =1.00). The mean duration of hospitalization for children receiving bicarbonate was 23% (16 hours) longer than children who did not receive bicarbonate in the multivariate analysis ( P =.07) and 37% (22 hours) longer in the matched pair analysis ( P =.01). The mean rate of metabolic recovery by three distinct measures was similar between groups, and the sample had 80% power to detect differences of 14% to 29% in these measures. Conclusion: We found no evidence that adjunctive bicarbonate improved clinical outcome in children with severe DKA. The rate of metabolic recovery and complications were similar in patients treated with and without bicarbonate, and prolonged hospitalizations were noted in the bicarbonate group. We conclude that adjunctive bicarbonate is unnecessary and potentially disadvantageous in severe pediatric DKA. [Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, Zimmerman GJ: Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med January 1998;31:41-48.]