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Powell E, Keller AP, Galvagno SM. Advanced Critical Care Techniques in the Field. Crit Care Clin 2024; 40:463-480. [PMID: 38796221 DOI: 10.1016/j.ccc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Critical care principles and techniques continue to hold promise for improving patient outcomes in time-dependent diseases encountered by emergency medical services such as cardiac arrest, acute ischemic stroke, and hemorrhagic shock. In this review, the authors discuss several current and evolving advanced critical care modalities, including extracorporeal cardiopulmonary resuscitation, resuscitative endovascular occlusion of the aorta, prehospital thrombolytics for acute ischemic stroke, and low-titer group O whole blood for trauma patients. Two important critical care monitoring technologies-capnography and ultrasound-are also briefly discussed.
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Affiliation(s)
- Elizabeth Powell
- Program in Trauma, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Alex P Keller
- Medical Modernization and Plans Division, 162 Dodd Boulevard, Langley Air Force Base, VA 23665, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street, S11C16, Baltimore, MD 21201, USA.
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López-Izquierdo R, Zalama-Sánchez D, Rodrigo Enríquez DSG, Ana Ramos R, Laura Fadrique M, Mario Rodil M, Virginia Carbajosa R, Rubén Pérez G, Sanz-García A, Del Pozo Vegas C, Martín-Rodríguez F. Utility of non-invasive monitoring of exhaled carbon dioxide and perfusion index in adult patients in the emergency department. Am J Emerg Med 2024; 79:85-90. [PMID: 38401230 DOI: 10.1016/j.ajem.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Several noninvasive solutions are available for the assessment of patients at risk of deterioration. Capnography, in the form of end-tidal exhaled CO2 (ETCO2) and perfusion index (PI), could provide relevant information about patient prognosis. The aim of the present project was to determine the association of ETCO2 and PI with mortality of patients admitted to the emergency department (ED). METHODS Multicenter, prospective, cohort study of adult patients with acute disease who needed continuous monitoring in the ED. The study included two tertiary hospitals in Spain between October 2022 and June 2023. The primary outcome of the study was in-hospital mortality (all-cause). Demographics, vital signs, ETCO2 and PI were collected. RESULTS A total of 687 patients were included in the study. The in-hospital mortality rate was 6.8%. The median age was 79 years (IQR: 69-86), and 63.3% were males. The median ETCO2 value was 30 mmHg (26-35) in survivors and 23 mmHg (16-30) in nonsurvivors (p = 0.001). For the PI, the medians were 4.7% (2.8-8.1) for survivors and 2.5% (0.98-4-4) for nonsurvivors (p < 0.001). The model that presented the best AUC was age (odds ratio (OR): 1.02 (1.00-1.05)), the respiratory rate (OR: 1.06 (1.02-1.11)), and the PI (OR: 0.83 (0.75-0.91)), with a result of 0.840 (95% CI: 0.795-0.886); the model with the respiratory rate (OR: 1.05 (1.01-1.10)), the PI (OR: 0.84 (0.76-0.93)), and the ETCO2 (no statistically significant OR), with an AUC of 0.838 (95% CI: 0.787-0.889). CONCLUSIONS The present study showed that the PI and respiratory rate are independently associated with in-hospital mortality. Both the PI and ETCO2 are predictive parameters with improved prognostic performance compared with that of standard vital signs.
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Affiliation(s)
- Raúl López-Izquierdo
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain; Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | | | | | | | | | - Muñoz Mario Rodil
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - García Rubén Pérez
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Ancor Sanz-García
- Faculty of Health Sciences, Universidad de Castilla la Mancha, Talavera de la Reina, Spain.
| | - Carlos Del Pozo Vegas
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Emergency Department, Hospital Clínico Universitario. Valladolid, Spain
| | - Francisco Martín-Rodríguez
- Faculty of Medicine, Universidad de Valladolid, Valladolid, Spain; Advanced Life Support, Emergency Medical Services (SACYL), Valladolid, Spain
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Peng P, Manini AF. Diagnostic utility of capnography in emergency department triage for screening acidemia: a pilot study. Int J Emerg Med 2024; 17:57. [PMID: 38649817 PMCID: PMC11036727 DOI: 10.1186/s12245-024-00631-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Capnography is a quantitative and reliable method of determining the ventilatory status of patients. We describe the test characteristics of capnography obtained during Emergency Department triage for screening acidemia. RESULTS We performed an observational, pilot study of adult patients presenting to Emergency Department (ED) triage. The primary outcome was acidemia, as determined by the basic metabolic panel and/or blood gas during the ED visit. Secondary outcomes include comparison of estimated and measured respiratory rates (RR), relationships between end-tidal CO2 (EtCO2) and venous partial pressure of CO2, admission disposition, in-hospital mortality during admission, and capnogram waveform analysis. A total of 100 adult ED encounters were included in the study and acidemia ([Formula: see text] or [Formula: see text]) was identified in 28 patients. The measured respiratory rate (20.3 ± 6.4 breaths/min) was significantly different from the estimated rate (18.4 ± 1.6 breaths/min), and its area under the receiver operating curve (c-statistic) to predict acidemia was only 0.60 (95% CI 0.51-0.75, p = 0.03). A low end-tidal CO2 (EtCO2 < 32 mmHg) had positive (LR+) and negative (LR-) likelihood ratios of 4.68 (95% CI 2.59-8.45) and 0.34 (95% CI 0.19-0.61) for acidemia, respectively-corresponding to sensitivity 71.4% (95% CI 51.3-86.8) and specificity 84.7% (95% CI 74.3-92.1). The c-statistic for EtCO2 was 0.849 (95% CI 0.76-0.94, p = 0.00). Waveform analysis further revealed characteristically abnormal capnograms that were associated with underlying pathophysiology. CONCLUSIONS Capnography is a quantitative method of screening acidemia in patients and can be implemented feasibly in Emergency Department triage as an adjunct to vital signs. While it was shown to have only modest ability to predict acidemia, triage capnography has wide generalizability to screen other life-threatening disease processes such as sepsis or can serve as an early indicator of clinical deterioration.
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Affiliation(s)
- Paul Peng
- Department of Emergency Medicine, The State University of New Jersey, 08901, Rutgers, New Brunswick, NJ, United States of America.
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 10029, New York, NY, United States of America
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Wham C, Morin T, Sauaia A, McIntyre R, Urban S, McVaney K, Cohen M, Cralley A, Moore EE, Campion EM. Prehospital ETCO 2 is predictive of death in intubated and non-intubated patients. Am J Surg 2023; 226:886-890. [PMID: 37563074 DOI: 10.1016/j.amjsurg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index = 22 mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p = 0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p = 0.03). CONCLUSION Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.
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Affiliation(s)
- Courtney Wham
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Theresa Morin
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Angela Sauaia
- University of Colorado, School of Public Health (AS), United States.
| | - Robert McIntyre
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Shane Urban
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Kevin McVaney
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Mitchell Cohen
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Alexis Cralley
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Eric M Campion
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
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Stojek L, Bieler D, Neubert A, Ahnert T, Imach S. The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature. Eur J Trauma Emerg Surg 2023; 49:1727-1739. [PMID: 36703080 PMCID: PMC10449679 DOI: 10.1007/s00068-023-02226-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 01/07/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm. METHODS A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle-Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193. RESULTS 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm. DISCUSSION A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).
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Affiliation(s)
- Leonard Stojek
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Dan Bieler
- Department of Orthopedics and Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Anne Neubert
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
- TraumaEvidence @ German Society of Traumatology, Berlin, Germany
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany.
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Ladde JG, Miller S, Chin K, Feffer C, Gulenay G, Kepple K, Hunter C, Thundiyil JG, Papa L. End-tidal carbon dioxide measured at emergency department triage outperforms standard triage vital signs in predicting in-hospital mortality and intensive care unit admission. Acad Emerg Med 2023; 30:832-841. [PMID: 36802204 DOI: 10.1111/acem.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVES This study assessed the ability of end-tidal carbon dioxide (ETCO2 ) in predicting in-hospital mortality and intensive care unit (ICU) admission compared to standard vital signs at ED triage as well as comparing to measures of metabolic acidosis. METHODS This prospective study enrolled adult patients presenting to the ED of a tertiary care Level I trauma center over 30 months. Patients had standard vital signs measured along with exhaled ETCO2 at triage. Outcome measures included in-hospital mortality; ICU admission; and correlations with lactate, sodium bicarbonate (HCO3 ), and anion gap. RESULTS There were 1136 patients enrolled and 1091 patients with outcome data available. There were 26 (2.4%) patients who did not survive to hospital discharge. Mean ETCO2 levels were 34 (33-34) in survivors and 22 (18-26) nonsurvivors (p < 0.001). The area under the curve (AUC) for predicting in-hospital mortality for ETCO2 was 0.82 (0.72-0.91). In comparison the AUC for temperature was 0.55 (0.42-0.68), respiratory rate (RR) 0.59 (0.46-0.73), systolic blood pressure (SBP) 0.77 (0.67-0.86), diastolic blood pressure (DBP) 0.70 (0.59-0.81), heart rate (HR) 0.76 (0.66-0.85), and oxygen saturation (SpO2 ) 0.53 (0.40-0.67). There were 64 (6%) patients admitted to the ICU, and the ETCO2 AUC for predicting ICU admission was 0.75 (0.67-0.80). In comparison the AUC for temperature was 0.51, RR 0.56, SBP 0.64, DBP 0.63, HR 0.66, and SpO2 0.53. Correlations between expired ETCO2 and serum lactate, anion gap, and HCO3 were rho = -0.25 (p < 0.001), rho = -0.20 (p < 0.001), and rho = 0.330 (p < 0.001), respectively. CONCLUSIONS ETCO2 was a better predictor of in-hospital mortality and ICU admission than the standard vital signs at ED triage. ETCO2 correlated significantly with measures of metabolic acidosis.
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Affiliation(s)
- Jay G Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Stacie Miller
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Kevin Chin
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Cole Feffer
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - George Gulenay
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Kirsten Kepple
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Christopher Hunter
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Josef G Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
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Oskay A, Uluturk M, Cevirme H, Oskay T, Senol H, Ozen M, Seyit M, Yilmaz A, Turkcuer I. The effect of surgical masks on vital signs and EtCO 2 in patients on oxygen therapy. Ir J Med Sci 2023; 192:395-402. [PMID: 35243584 PMCID: PMC8893239 DOI: 10.1007/s11845-022-02963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are conflicting data on the effects of masks on vital signs and end-tidal CO2 (EtCO2) values in the literature. AIMS This study aims to evaluate the changes in the vital parameters and EtCO2 values of the patients who were administered oxygen through nasal cannula (NC) and simple oxygen mask (SOM) and wore surgical masks (SM) on top during their treatment. METHODS The prospective, observational study was conducted from January 2021, over consecutive 30 days, in the emergency department of a tertiary-care university hospital. The vital signs and EtCO2 values of the subjects administered O2 were noted at the time of arrival and at the 30th and 120th minutes of treatment. Changes in vital signs and EtCO2 values were compared with regard to NC-SM and SOM-SM applications over a 120-min study period. RESULTS Sixty-eight subjects were included in two groups (NC-SM [n = 49] and SOM-SM [n = 19]). At the 120th minute, a decrease in systolic and diastolic blood pressure, heart rate, and respiratory rate and an increase in oxygen saturation were observed in the group including all subjects. After decreasing slightly in the first 30 min, the EtCO2 value remained stable. CONCLUSIONS NC-SM and SOM-SM applications do not affect adversely, and even seem to lead to recovery of, the vital signs and EtCO2 values during 120 min in subjects with acute complaints.
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Affiliation(s)
- Alten Oskay
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey.
| | - Mehmet Uluturk
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Hazan Cevirme
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Tulay Oskay
- Division of Cardiology, Bucak State Hospital, 15300, Burdur, Turkey
| | - Hande Senol
- Department of Biostatistics, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Mert Ozen
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Murat Seyit
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Atakan Yilmaz
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
| | - Ibrahim Turkcuer
- Department of Emergency Medicine, School of Medicine, Pamukkale University, Kinikli Campus, 20700, Denizli, Turkey
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Thacker J, Stroud A, Carge M, Baldwin C, Shahait AD, Tyburski J, Dolman H, Tarras S. Utility of arterial CO2 - End-tidal CO2 gap as a mortality indicator in the surgical ICU. Am J Surg 2022. [DOI: 10.1016/j.amjsurg.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Portelli Tremont JN, Caldas RA, Cook N, Udekwu PO, Moore SM. Low initial in-hospital end-tidal carbon dioxide predicts poor patient outcomes and is a useful trauma bay adjunct. Am J Emerg Med 2022; 56:45-50. [DOI: 10.1016/j.ajem.2022.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022] Open
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Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, LaRiccia A, Moore S, Tann K, Leskovan J, Camazine M, Barnes SL, Otaibi B, Hazelton JP, Jacobson LE, Williams J, Castillo R, Stewart NJ, Elterman JB, Zier L, Goodman M, Elson N, Miner J, Hardman C, Kapoen C, Mendoza AE, Schellenberg M, Benjamin E, Wakam GK, Alam HB, Kornblith LZ, Callcut RA, Coleman LE, Shatz DV, Burruss S, Linn AC, Perea L, Morgan M, Schroeppel TJ, Stillman Z, Carrick MM, Gomez MF, Berne JD, McIntyre RC, Urban S, Nahmias J, Tay E, Cohen M, Moore EE, McVaney K, Burlew CC. Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2022; 92:355-361. [PMID: 34686640 DOI: 10.1097/ta.0000000000003447] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
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Affiliation(s)
- Eric M Campion
- From the Department of Surgery (E.M.C., A.C., M. Cohen, E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; School of Public Health (A.S.), University of Colorado, Aurora, Colorado; Department of Surgery (R.C.B., A.T.B.), Erlanger Health System, Chattanooga, Tennessee; Department of Surgery (M.C.S., A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.M., K.T.), Wakemed, Raleigh, North Carolina; Department of Surgery (J.L.), Mercy Health, Toledo, Ohio; Department of Surgery (M. Camazine, S.L.B.), University of Missouri Health Care, Columbia, Missouri; Department of Surgery (B.O., J.P.H.), Penn State Health, Hershey, Pennsylvania; Department of Surgery (L.E.J., J.W.), Ascension, Indianapolis, Indiana; Department of Surgery (R.C., N.J.S.), St. Lukes University Health Network, Bethlehem, Pennsylvania; Department of Surgery (J.B.E., L.Z.), UCHealth Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (M.G., N.E.), University of Cincinnati, Cincinnati, Ohio; Department of Surgery (J.M., C.H.), Premier Health Miami Valley, Dayton, Ohio; Department of Surgery (C.K., A.E.M.), Massachusetts General Hospital, Boston, Massachusetts; USC Medical Center, University of Southern California (M.S., E.B.), Los Angeles, California; Department of Surgery (G.K.W., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (L.Z.K., R.A.C.), Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; Department of Surgery (L.E.C., D.V.S.), University of California, Davis, Sacramento, California; Department of Surgery (S.B., A.C.L.), Loma Linda University Health, Loma Linda, California; Department of Surgery (L.P., M.M.), Penn Medicine, Philadelphia, Pennsylvania; Department of Surgery (T.J.S., Z.S.), UCHealth Memorial Hospital, Springs Colorado, Colorado; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (M.F.G., J.D.B.), Broward Health, Ft. Lauderdale, Florida; Department of Surgery (R.C.M., S.U.), University of Colorado Anschutz, Aurora, Colorado; University of California, Irvine (J.N., E.T.), Irvine, CA; and Denver Paramedics, Department of Emergency Medicine (K.M.), Denver Health Medical Center, Denver, Colorado
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Bulger N, Harrington B, Krieger J, Latimer A, Arbabi S, Counts CR, Sayre M, Maynard C, Bulger EM. Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival. J Trauma Acute Care Surg 2021; 91:457-464. [PMID: 34432752 DOI: 10.1097/ta.0000000000003312] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients. METHODS A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock. RESULTS Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg. CONCLUSION Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Natalie Bulger
- From the Department of Surgery (S.A., E.M.B.), University of Washington, Seattle, Washington; Department of Emergency Medicine (N.B., B.H., A.L., C.R.C., M.S.), University of Washington, Seattle, Washington; Department of Critical Care (J.K.), University of Washington, Seattle, Washington; Seattle Fire Department (A.L., C.R.C., M.S.), Seattle, Washington; and University of Washington School of Public Health (C.M.), Seattle, Washington
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Bryant MK, Portelli Tremont JN, Patel Z, Cook N, Udekwu P, Reid T, Maine RG, Moore SM. "Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients". Injury 2021; 52:2502-2507. [PMID: 34289938 DOI: 10.1016/j.injury.2021.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Current guidelines continue to lead to under- and over-triage of injured patients in the pre-hospital setting. End-tidal carbon dioxide (ETCO2) has been correlated with mortality and hemorrhagic shock in trauma patients. This study examines the correlation between ETCO2 and in-hospital outcomes among non-intubated patients in the pre-hospital setting. METHODS We retrospectively studied a cohort of non-intubated adult trauma patients with initial pre-hospital side-stream capnography-obtained ETCO2 presenting via ground transport from a single North Carolina EMS agency to a level one trauma center from January 2018 to December 2018. Using the Liu method, the optimal threshold for low ETCO2 was ≤ 28.5 mmHg. RESULTS Initial pre-hospital ETCO2 was recorded for 324 (22.0%) of 1473 patients with EMS data. Patients with low ETCO2 (N = 98, 30.3% of cohort) were older (median 58y vs 45y), but mechanisms of injury and scene vital signs were similar (p>0.05) between low and normal/high ETCO2 cohorts. Median injury severity score (ISS) did not differ significantly between the low and normal/high ETCO2 groups (5 vs 8, p=0.48). Compared to normal/high ETCO2, low ETCO2 correlated with increased unadjusted odds of mortality (OR 5.06), in-hospital complications (OR 2.06), and blood transfusion requirement (OR 3.05), p<0.05. Low ETCO2 was associated with 7.25 odds of mortality (95% CI 2.19,23.97, p=0.001) and 3.94 odds of blood transfusion (95% CI 1.32-11.78) after adjusting for age, ISS, and scene GCS. All but one of the massive transfusion patients (N = 8/9) had a low pre-hospital ETCO2. CONCLUSIONS Low initial pre-hospital ETCO2 associates with poor clinical outcomes despite similar ISS and mechanisms of injury. ETCO2 is a potentially useful pre-hospital point-of-care tool to aid triage of trauma patients as it may identify hemorrhaging patients and predict mortality.
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Affiliation(s)
- Mary Kate Bryant
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA; Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Jaclyn N Portelli Tremont
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA; Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Zachary Patel
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Nicole Cook
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Pascal Udekwu
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Trista Reid
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Rebecca G Maine
- Department of Surgery, University of Washington, 3024 New Bern Ave, Andrews Center, Suite 302, Seattle 27610, WA, USA.
| | - Scott M Moore
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
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Barneck M, Papa L, Cozart A, Lentine K, Ladde J, Nguyen L, Mayfield J, Thundiyil J. The utility of transcutaneous carbon dioxide measurements in the emergency department: A prospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12513. [PMID: 34296208 PMCID: PMC8286116 DOI: 10.1002/emp2.12513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Rapid identification of patients with occult injury and illness in the emergency department can be difficult. Transcutaneous carbon dioxide (TCO2) and oxygen (TO2) measurements may be non-invasive surrogate markers for the identification of such patients. OBJECTIVES To determine if TCO2 or TO2 are useful adjuncts for identifying severe illness and the correlation between TCO2, lactate, and end tidal carbon dioxide (ETCO2). METHODS Prospective TCO2 and TO2 measurements at a tertiary level 1 trauma center were obtained using a transcutaneous sensor on 300 adult patients. Severe illness was defined as death, intensive care unit (ICU) admission, bilevel positive airway pressure, vasopressor use, or length of stay >2 days. TCO2 and TO2 were compared to illness severity using t tests and correlation coefficients. RESULTS Mean TO2 did not differ between severe illness (58.9, 95% CI 54.9-62.9) and non-severe illness (58.0, 95% CI 54.7-61.1). Mean TCO2 was similar between severe (34.6, 95% CI 33-36.2) vs non-severe illness (35.9, 95% CI 34.7-37.1). TCO2 was 28.7 (95% CI 24.0-33.4) for ICU vs. 35.9 (95% CI 34.9-36.9) for non-ICU patients. The mean TCO2 in those with lactate > 2.0 was 29.8 (95% CI 25.8-33.8) compared with 35.7 (95% CI 34.9-36.9) for lactate < 2.0. TCO2 was not correlated with ETCO2 (r = 0.32, 95% CI 0.22-0.42). CONCLUSION TCO2 could be a useful adjunct for identifying significant injury and illness and patient outcomes in an emergency department (ED) population. TO2 did not predict severe illness. TCO2 and ETCO2 are only moderately correlated, indicating that they are not equivalent and may be useful under different circumstances.
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Affiliation(s)
| | - Linda Papa
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Ashley Cozart
- College of MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Kain Lentine
- College of MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Jay Ladde
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Linh Nguyen
- College of MedicineFlorida State UniversityTallahasseeFloridaUSA
| | - Jeremy Mayfield
- College of MedicineUniversity of Central FloridaOrlandoFloridaUSA
| | - Josef Thundiyil
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
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Association of Ventilation during Initial Trauma Resuscitation for Traumatic Brain Injury and Post-Traumatic Outcomes: A Systematic Review. Prehosp Disaster Med 2021; 36:460-465. [PMID: 34057405 DOI: 10.1017/s1049023x21000534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In the absence of evidence of acute cerebral herniation, normal ventilation is recommended for patients with traumatic brain injury (TBI). Despite this recommendation, ventilation strategies vary during the initial management of patients with TBI and may impact outcome. The goal of this systematic review was to define the best evidence-based practice of ventilation management during the initial resuscitation period. METHODS A literature search of PubMed, CINAHL, and SCOPUS identified studies from 2009 through 2019 addressing the effects of ventilation during the initial post-trauma resuscitation on patient outcomes. RESULTS The initial search yielded 899 articles, from which 13 were relevant and selected for full-text review. Six of the 13 articles met the inclusion criteria, all of which reported on patients with TBI. Either end-tidal carbon dioxide (ETCO2) or partial pressure carbon dioxide (PCO2) were the independent variables associated with mortality. Decreased rates of mortality were reported in patients with normal PCO2 or ETCO2. CONCLUSIONS Normoventilation, as measured by ETCO2 or PCO2, is associated with decreased mortality in patients with TBI. Preventing hyperventilation or hypoventilation in patients with TBI during the early resuscitation phase could improve outcome after TBI.
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Willis RG, Cunningham KW, Troia PA, Gutierrez AS, Christmas AB, Brintzenhoff R, Sing RF. Prehospital End-Tidal CO 2: A Superior Marker for Mortality Risk in the Acutely Injured Patient. Am Surg 2021; 88:2011-2016. [PMID: 34047203 DOI: 10.1177/00031348211023401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Emergency medical personnel must expeditiously triage acutely injured patients to the appropriate medical facility. Efficient and objective variables to facilitate this process and provide information to the receiving trauma center are needed. Currently, multiple variables are used to prognosticate injury severity and risk of mortality including vital signs, mental status, lactate, and base excess. We investigated the prehospital use of end-tidal carbon dioxide (ETCO2) as a noninvasive physiologic measure that can be obtained in the acutely injured patient. METHODS We performed a retrospective analysis of 557 acutely injured patients over 2 years at a Level 1 trauma center. All patients arriving as trauma activations with ETCO2 measurements were included in analysis. End-tidal carbon dioxide measurements were categorized as low, normal, and high based on reference levels. Mortality was the primary outcome. Secondary receiver operator curves (ROC) for base excess, venous lactate, blood pressure, and venous pH were compared. We hypothesized ETCO2 levels would be able to predict mortality. RESULTS End-tidal carbon dioxide levels conferred a mortality rate of 38%, 17.3%, and 2.9% for low, normal, and high, respectively (P < .001). Receiver operator curve analysis produced an area under the curve predictive value for ETCO2 (.748) which was superior to lactate (.660), SBP (.578), pH (.560), and base excess (.497). DISCUSSION End-tidal carbon dioxide is a more sensitive and specific predictor of mortality in the acutely injured patient compared to venous lactate, base deficit, blood pressure, or venous pH. Additional studies are needed to determine if ETCO2 can be used as an effective prehospital adjunct to prevent mortality in acutely injured patients.
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Affiliation(s)
- Robert G Willis
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Kyle W Cunningham
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Paola A Troia
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Ashley S Gutierrez
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Ashley B Christmas
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Rita Brintzenhoff
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
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Martín-Rodríguez F, López-Izquierdo R, del Pozo Vegas C, Delgado-Benito JF, Ortega GJ, Castro Villamor MA, Sanz-García A. Association of Prehospital Oxygen Saturation to Inspired Oxygen Ratio With 1-, 2-, and 7-Day Mortality. JAMA Netw Open 2021; 4:e215700. [PMID: 33847751 PMCID: PMC8044733 DOI: 10.1001/jamanetworkopen.2021.5700] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The early identification of patients at high risk of clinical deterioration represents one of the greatest challenges for emergency medical services (EMS). OBJECTIVE To assess whether use of the ratio of prehospital oxygen saturation measured by pulse oximetry (Spo2) to fraction of inspired oxygen (Fio2) measured during initial contact by EMS with the patient (ie, the first Spo2 to Fio2 ratio) and 5 minutes before the patient's arrival at the hospital (ie, the second Spo2 to Fio2 ratio) can predict the risk of early in-hospital deterioration. DESIGN, SETTING, AND PARTICIPANTS A prospective, derivation-validation prognostic cohort study of 3606 adults with acute diseases referred to 5 tertiary care hospitals in Spain was conducted between October 26, 2018, and June 30, 2020. Eligible patients were recruited from among all telephone requests for EMS assistance for adults who were later evacuated with priority in advanced life support units to the referral hospitals during the study period. MAIN OUTCOMES AND MEASURES The primary outcome was hospital mortality from any cause within the first, second, third, or seventh day after EMS transport to the hospital. The main measure was the Spo2 to Fio2 ratio. RESULTS A total of 3606 participants comprised 2 separate cohorts: the derivation cohort (3081 patients) and the validation cohort (525 patients). The median age was 69 years (interquartile range, 54-81 years), and 2122 patients (58.8%) were men. The overall mortality rate of the patients in the study cohort ranged from 3.6% for 1-day mortality (131 patients) to 7.1% for 7-day mortality (256 patients). The best model performance was for 2-day mortality with the second Spo2 to Fio2 ratio with an area under the curve of 0.890 (95% CI, 0.829-0.950; P < .001), although the other outcomes also presented good results. In addition, a risk-stratification model was generated. The optimal cutoff resulted in the following ranges of Spo2 to Fio2 ratios: 50 to 100 for high risk of mortality, 101 to 426 for intermediate risk, and 427 to 476 for low risk. CONCLUSIONS AND RELEVANCE This study suggests that use of the prehospital Spo2 to Fio2 ratio was associated with improved management of patients with acute disease because it accurately predicts short-term mortality.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Advanced Life Support, Emergency Medical Services, Valladolid, Spain
| | - Raúl López-Izquierdo
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carlos del Pozo Vegas
- Faculty of Medicine, Valladolid University, Valladolid, Spain
- Emergency Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Guillermo J. Ortega
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | | | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa, Madrid, Spain
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Prehospital end-tidal carbon dioxide predicts massive transfusion and death following trauma. J Trauma Acute Care Surg 2020; 89:703-707. [PMID: 32590557 DOI: 10.1097/ta.0000000000002846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The lack of an accurate marker of prehospital hemorrhagic shock limits our ability to triage patients to the correct level of care, delays treatment in the emergency department, and inhibits our ability to perform prehospital interventional research in trauma. End-tidal carbon dioxide (ETCO2) is the measurement of alveolar carbon dioxide concentration at end expiration and is measured noninvasively in the ventilator circuit for intubated patients in continuous manner. Several hospital-based studies have been able to demonstrate that either low or decreasing levels of ETCO2 as well as disparities between ETCO2 and plasma carbon dioxide correlate with increasing mortality in trauma. We hypothesized that prehospital ETCO2 values will be predictive of mortality and need for massive transfusion following injury. METHODS This is a single-center retrospective study from an urban level 1 trauma center. We reviewed all intubated adult patients transported for injury who had prehospital ETCO2 values available. Unadjusted comparisons of continuous variables were done with the Wilcoxon two-sample test. The predictive performance of prehospital ETCO2, the prehospital shock index, and prehospital systolic blood pressure were assessed and compared using areas under the receiver operating characteristic curves. Optimal cutoffs were estimated by maximizing the Youden index. Massive transfusion was defined as >10 U of blood or death in 24 hours. RESULTS A total of 173 patients were identified with prehospital ETCO2 values during the 2-year study period. Population was 78.5% male with a median age of 37.5 years (interquartile range, 23.5-53.5 years). Injury mechanism was penetrating in 22.8%. This cohort had a median Injury Severity Score of 26 (interquartile range, 17-36), massive transfusion rate of 34.7%, and mortality of 42.1%. In the evaluation of prediction of postinjury mortality and massive transfusion, ETCO2 outperformed systolic blood pressure and shock index, but these differences did not reach statistical significance. CONCLUSION End-tidal carbon dioxide is a novel prehospital predictor of mortality and massive transfusion after injury. LEVEL OF EVIDENCE Prognostic/Epidemiologic, level III.
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Correlation of Nasal Cannula End-Tidal Carbon Dioxide Concentration With Need for Critical Resources for Blunt Trauma Patients Triaged to Lower-Tier Trauma Activation. J Trauma Nurs 2020; 27:88-95. [PMID: 32132488 DOI: 10.1097/jtn.0000000000000492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients assigned lower-tier trauma activation may be undertriaged. Delayed recognition and intervention may adversely affect outcome. For critically injured intubated patients, research shows that abnormally low end-tidal carbon dioxide (EtCO2) values correlate with need for blood transfusion, surgery, and mortality. The purpose of this study was to evaluate EtCO2 monitoring for patients triaged to lower-tier trauma activation. EtCO2 monitoring may aid in the recognition of patients who have greater needs than anticipated. This is a prospective observational study conducted at a Level I trauma center. Potential subjects presenting from the field were identified by lower-tier trauma activation for blunt mechanism. EtCO2 measurements acquired using nasal cannula sidestream technology were prospectively recorded in the trauma bay during the initial assessment. The medical record and trauma registry were queried for demographics, injury data, mortality, and critical resource data defined as intubation, blood transfusion, surgery, intensive care unit admission, and vasoactive medication infusion. EtCO2 data were obtained for 682 subjects during a 10.5-month period. Following exclusions, 262 patients were enrolled for data collection. EtCO2 values less than 30 mmHg were significantly associated with blood transfusion (p = .03) but not with other critical resources or mortality. Although capnography had limited utility for patients triaged to lower-tier trauma activation, EtCO2 values less than 30 mmHg correlated with blood transfusion, consistent with previous studies of critically injured intubated patients. EtCO2 monitoring is noninvasive and may serve as a simple prompt for earlier initiation of blood transfusion, a resource-intensive intervention.
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Daya MR, Cheney TP, Chou R, Fu R, Newgard CD, O'Neil ME, Wasson N, Hart EL, Totten AM. Out-of-hospital Respiratory Measures to Identify Patients With Serious Injury: A Systematic Review. Acad Emerg Med 2020; 27:1312-1322. [PMID: 32569406 DOI: 10.1111/acem.14055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/27/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective was to systematically review the published literature on the diagnostic accuracy of out-of-hospital respiratory measures for identifying patients with serious injury, focusing on measures feasible for field triage by emergency medical services personnel. METHODS We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from January 1, 1996, through August 31, 2017. We included studies on the diagnostic accuracy (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) for all respiratory measures used to identify patients with serious injury (resource use, serious anatomic injury, and mortality). We assessed studies for risk of bias and strength of evidence (SOE). We performed meta-analysis for measures with sufficient data. RESULTS We identified 46 articles reporting results of 44 studies. Out-of-hospital respiratory measures included respiratory rate, pulse oximetry, and airway support. Meta-analysis was only possible for respiratory rate, which demonstrated a pooled sensitivity for serious injury of 13% (95% confidence interval [CI] = 5 to 29, I2 = 97.8%), specificity of 96% (95% CI = 83 to 99, I2 = 99.6%), and AUROC of 0.70 (95% CI = 0.66 to 0.79, I2 = 16.6%). For oxygen saturation, sensitivity ranged from 13% to 63%; specificity, 85% to 99%; and AUROC, 0.53 to 0.76. Need for airway support had a sensitivity of 8% to 53% and specificity of 61% to 100%; studies did not report AUROC. Across respiratory measures, the SOE was low. Other respiratory measures (pH, end-tidal carbon dioxide [CO2 ], and sublingual partial pressure of CO2 ) were reported only in emergency department studies. CONCLUSIONS Data on the accuracy of out-of-hospital respiratory measures for field triage are limited and of low quality. Based on available research, respiratory rate, oxygen saturation, and need for airway intervention all have low sensitivity, high specificity, and poor to fair discrimination for identifying seriously injured patients.
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Affiliation(s)
- Mohamud R. Daya
- From the Department of Emergency Medicine Center for Policy and Research in Emergency Medicine Oregon Health & Science University Portland OR USA
| | - Tamara P. Cheney
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
| | - Roger Chou
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
| | - Rongwei Fu
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Division of Biostatistics Oregon Health & Science University–Portland State University School of Public Health Portland OR USA
| | - Craig D. Newgard
- From the Department of Emergency Medicine Center for Policy and Research in Emergency Medicine Oregon Health & Science University Portland OR USA
| | - Maya E. O'Neil
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
- and the Veterans Administration Portland Health Care System Portland OR USA
| | - Ngoc Wasson
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
| | - Erica L. Hart
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
| | - Annette M. Totten
- the Pacific Northwest Evidence‐based Practice Center Portland OR USA
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland OR USA
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Hilbert-Carius P, Struck MF, Hofer V, Hinkelbein J, Rognås L, Adler J, Christian MD, Wurmb T, Bernhard M, Hossfeld B. Mechanical ventilation of patients in helicopter emergency medical service transport: an international survey. Scand J Trauma Resusc Emerg Med 2020; 28:112. [PMID: 33208195 PMCID: PMC7672415 DOI: 10.1186/s13049-020-00801-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature. METHOD We conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests. RESULTS Out of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p < 0.01) and positive end-expiratory pressure (p = 0.04) of the patients were significantly higher compared to first patient contact. CONCLUSION In this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS. TRIAL REGISTRATION The survey was prospectively registered at Research Registry ( researchregistry2925 ).
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Affiliation(s)
- Peter Hilbert-Carius
- BG Klinikum Bergmannstrost Halle gGmbH, Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, and HEMS "Christoph 84" and "Christoph 85", DRF-Luftrettung, Halle (Saale), Germany
| | - Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph 33" and "Christoph 71" Senftenberg, University Hospital Leipzig, Leipzig, Germany.
| | - Veronika Hofer
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Jochen Hinkelbein
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph Rheinland", University Hospital Cologne, Cologne, Germany
| | | | - Jörn Adler
- Luxembourg Air Rescue A.s.b.l., Sandweiler, Luxembourg
| | | | - Thomas Wurmb
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Björn Hossfeld
- Federal Armed Forces Hospital, Ulm, Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, and HEMS "Christoph 22" Ulm, Ulm, Germany
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Demaree C, Simpson JT, Smith A, Guidry C, McGrew P, Schroll R, McGinness C, Tatum D, Duchesne J. Intraoperative End-Tidal CO2 as a Predictor of Mortality in Trauma Patients Receiving Massive Transfusion Protocol. Am Surg 2020. [DOI: 10.1177/000313481908501217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher Demaree
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - John Tyler Simpson
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Alison Smith
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Chrissy Guidry
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Patrick McGrew
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Rebecca Schroll
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Clifton McGinness
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Danielle Tatum
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
| | - Juan Duchesne
- Department of Surgery Tulane University School of Medicine New Orleans, Louisiana
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End-tidal carbon dioxide underestimates plasma carbon dioxide during emergent trauma laparotomy leading to hypoventilation and misguided resuscitation: A Western Trauma Association Multicenter Study. J Trauma Acute Care Surg 2020; 87:1119-1124. [PMID: 31389913 DOI: 10.1097/ta.0000000000002469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. METHODS Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. RESULTS Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. CONCLUSION Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. LEVEL OF EVIDENCE Therapeutic, level IV.
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Utilizing End-Tidal Carbon Dioxide to Diagnose Diabetic Ketoacidosis in Prehospital Patients with Hyperglycemia. Prehosp Disaster Med 2020; 35:281-284. [DOI: 10.1017/s1049023x20000485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AbstractBackground:Early identification of diabetic ketoacidosis (DKA) may improve clinical outcomes. Prior studies suggest exhaled end tidal carbon dioxide (ETCO2) provides a non-invasive, real-time method to screen for DKA in the emergency department (ED).Methods:This a retrospective cohort study among patients who activated Emergency Medical Services (EMS) during a one-year period. Initial out-of-hospital vital signs documented by EMS personnel, including ETCO2 and first recorded blood glucose level (BGL), as well as in-hospital records, including laboratory values and diagnosis, were collected. The main outcome was the association between ETCO2 and the diagnosis of DKA.Results:Of the 118 patients transported with hyperglycemia (defined by BGL >200), six (5%) were diagnosed with DKA. The mean level of ETCO2 in those without DKA was 35mmHg (95% CI, 33-38mmHg) compared to mean levels of 15mmHg (95% CI, 8-21mmHg) in those with DKA (P <.001). The Area Under the Receiver Operating Characteristics (ROC) Curve (AUC) for ETCO2 identifying DKA was 0.96 (95% CI, 0.92-1.00). The correlation coefficient between ETCO2 and serum bicarbonate (HCO3) was 0.436 (P <.001) and the correlation coefficient between ETCO2 and anion gap was -0.397 (P <.001).Conclusion:Among patients with hyperglycemia, prehospital levels of ETCO2 were significantly lower in patients with DKA compared to those without and were predictive of the diagnosis of DKA. Furthermore, out-of-hospital ETCO2 was significantly correlated with measures of metabolic acidosis.
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Abstract
INTRODUCTION In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs. METHODS The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative. RESULTS Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS. CONCLUSION This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.
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Waack J, Shepherd M, Andrew E, Bernard S, Smith K. Delayed Sequence Intubation by Intensive Care Flight Paramedics in Victoria, Australia. PREHOSP EMERG CARE 2018; 22:588-594. [PMID: 29405806 DOI: 10.1080/10903127.2018.1426665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Delayed sequence intubation (DSI) involves the administration of ketamine to facilitate adequate preoxygenation in the agitated patient. DSI was introduced into the Clinical Practice Guideline for Intensive Care Flight Paramedics in Victoria in late 2013. We aimed to describe the clinical characteristics of patients receiving DSI. METHODS A retrospective analysis was undertaken of patients who received DSI between January 1, 2014, and December 31, 2016, during both primary response and retrieval missions. Patients' clinical characteristics, DSI success rates, and complications were determined from electronic patient care records. RESULTS Forty patients received DSI during the study period. Of these, 32 were intubated to manage traumatic injury and the remaining 8 were intubated for medical reasons. On arrival of the first road ambulance, median oxygen saturation was 96.5%, and immediately prior to DSI the median was 98.0%. One patient had a period of self-limiting apnea (< 15 seconds) following ketamine administration. Oxygen saturation was either maintained or increased prior to laryngoscopy in all patients. Post-intubation, one patient experienced bradycardia (heart rate < 60 beats per minute), two patients had a systolic blood pressure drop of > 20 mm Hg, one patient experienced an increase in heart rate of > 20 beats per minute, and two patients had transient oxygen desaturation (< 85%). No patients experienced cardiac arrest or required surgical airway intervention. All patients were successfully intubated. After DSI, the median oxygen saturation was 100%. CONCLUSIONS DSI provides a reasonably safe and effective approach for intensive care flight paramedics in the preoxygenation of agitated, hypoxic patients in order to decrease the risk of peri-intubation desaturation and related hypoxic injury.
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Kim MW, Shin SD, Song KJ, Ro YS, Kim YJ, Hong KJ, Jeong J, Kim TH, Park JH, Kong SY. Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma. PREHOSP EMERG CARE 2018; 22:485-496. [DOI: 10.1080/10903127.2017.1416433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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