Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units

Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.

Age-Dependent Phenotypic Expression of a Pattern Dystrophy of the Retina

We studied a family with pattern dystrophy of the retina (PDR) in order to elucidate the clinical course of the disorder, relations between the different forms, and the mode of inheritance. Thirty-nine family members, representing three generations, underwent a thorough ophthalmological examination, with fluorescein angiography whenever a macular abnormality was suspected. Of family members over the age of 32 years, 46.7% showed signs of PDR. We classified the clinical forms of PDR in this family into four types: minimal lesion, pseudovitelliform type, butterfly-spider type, and late-stage lesion. These forms were predominant in the order cited in age groups 31-40 years, 41-50, 51-60, and > 60 years. Significant visual loss occurred only after the age of 50 years, when 8 of 14 eyes had visual acuity of less than 20/25. Inheritance was autosomal dominant. PDR presented different clinical forms in members of this family, and in successive age classes patterns of increasing severity prevailed. Thus, the different phenotypic forms apparently represent transient stages related to the age of the patient.

Relationship Between the Subcostal and Right Lateral Ultrasound Views of Inferior Vena Cava Collapse: Implications for Clinical Use of Ultrasonography

BACKGROUND

The collapsibility index of the inferior vena cava is traditionally visualized from the subcostal region in the sagittal plane, referred to here as cIVC_SS. Alternatively, the collapsibility index of the inferior vena cava can be visualized from the right midaxillary line in the coronal plane, referred to here as cIVC_RC. It is unclear whether values of cIVC_RC are comparable with values of cIVC_SS because the inferior vena cava collapses asymmetrically into an elliptical form, quantified as the flat ratio of the inferior vena cava (F-IVC). This study aimed (1) to establish if cIVC_RC is concordant or discordant to cIVC_SS, and (2) to describe how this concordance or discordance is related to F-IVC.

METHODS

This single-center cross-sectional study enrolled 110 spontaneously breathing patients. Values of cIVC_RC were compared with cIVC_SS. Performance of cIVC_RC ≥ 42% in predicting fluid responsiveness, defined as cIVC_SS ≥ 42%, was assessed. F-IVC was also correlated to the difference between cIVC_SS and cIVC_RC.

RESULTS

cIVC_RC ≥ 42% was 61.5% sensitive (95% CI, 31.58%-86.14%) and 67.1% specific (95% CI, 55.81%-77.06%) for predicting cIVC_SS ≥ 42%. cIVC_RC underestimated cIVC_SS. The degree of discordance between cIVC_RC and cIVC_SS was proportional to the value of F-IVC.

CONCLUSIONS

cIVC_RC and cIVC_SS measures are discordant, where cIVC_RC underestimates cIVC_SS. The degree of discordance is directly proportional to the value of F-IVC. Therefore, we recommend that cIVC_RC ≥ 42% be used to rule in, but not to rule out, fluid responsivity. Wherever possible, F-IVC should be assessed to understand the clinical relevance of cIVC_RC.

Psychological Skills to Improve Emergency Care Providers' Performance Under Stress

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

Quick SOFA Scores Predict Mortality in Adult Emergency Department Patients With and Without Suspected Infection

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.