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Bellini AR, Ross JT, Larson M, Pearson S, Robles AJ, Callcut RA. Do serial troponins predict the need for cardiac evaluation in trauma patients after ground-level fall? Trauma Surg Acute Care Open 2024; 9:e001328. [PMID: 38831977 PMCID: PMC11146413 DOI: 10.1136/tsaco-2023-001328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/10/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Troponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial troponin prompts serial testing until the level peaks. However, the high sensitivity of the test may lead to repeat testing that is of little clinical value. Here, we examine the role of serial troponins in predicting the need for further cardiac workup in trauma patients after sustaining a fall. Methods Retrospective review of all adult trauma activations for ground-level fall from January 1, 2021 to December 31, 2021 in patients who were hemodynamically and neurologically normal at presentation. Outcomes evaluated included need for cardiology consult, admission to cardiology service, outpatient cardiology follow-up, cardiology intervention and in-hospital mortality. Results There were 1555 trauma activations for ground-level fall in the study period. The cohort included 560 patients evaluated for a possible syncopal fall, hemodynamically stable, Glasgow Coma Scale score of 15, and with a troponin drawn at presentation. The initial median troponin was 20 ng/L (13-37). Second troponin values were drawn on 58% (median 33 ng/L (22-52)), with 42% of patients having an increase from first to second test. 29% of patients had a third troponin drawn (median 42 ng/L (26-67)). The initial troponin value was significantly associated with undergoing a subsequent echo (p=0.01), cardiology consult (p<0.01), admission for cardiac evaluation (p<0.01), cardiology follow-up (p<0.01), and in-hospital mortality (p=0.01); the initial troponin was not associated with cardiac intervention (p=0.91). An increase from the first to second troponin was not associated with any of outcomes of interest. Analysis was done with cut-off values of 30 ng/L, 50 ng/L, 70 ng/L, and 90 ng/L; a troponin T threshold of 19 ng/L was significant for cardiology consult (p=0.01) and cardiology follow-up (p=0.04). When the threshold was increased to 50 ng/L, it was also significant for admission for cardiac issue (p<0.01). When the threshold was increased to 90 ng/L, it was significant for the same three outcomes and in-hospital mortality (p=0.04). Conclusion The initial serum troponin has clinical value in identifying underlying cardiac disease in patients who present after ground-level fall; however, that serial testing is likely of little value. Further, using a cut-off of >50 ng/L as a threshold for further clinical evaluation would improve the utility of the test and likely reduce unnecessary hospital stays and costs for otherwise healthy patients. Level of evidence Level III.
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Affiliation(s)
- Alyssa R Bellini
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - James T Ross
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
- The Blood, Heart, Lung, and Immunology Research Center, Case Western Reserve University Hospital, Cleveland, Ohio, USA
| | - Madelyn Larson
- University of California Davis School of Medicine, Sacramento, California, USA
| | - Skyler Pearson
- University of California Davis School of Medicine, Sacramento, California, USA
| | - Anamaria J Robles
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Rachael A Callcut
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
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Zou M, Lu R, Jiang Y, Liu P, Tian B, Liang Y, Wang X, Jiang L. Association between toileting and falls in older adults admitted to the emergency department and hospitalised: a cross-sectional study. BMJ Open 2023; 13:e065544. [PMID: 37263694 DOI: 10.1136/bmjopen-2022-065544] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES This study aimed to explore the potential risk factors associated with toileting-related falls in community-dwelling older adults who presented to the emergency department and were subsequently hospitalised. DESIGN This was a cross-sectional study. SETTING AND PARTICIPANTS This study was conducted in two teaching hospitals in Shanghai, China between October 2019 and December 2021 among community-dwelling adults aged ≥60 years. METHODS In-person interviews, physical assessment and medical record review were performed to collect data on the characteristics and risk factors of falls. Associations of toileting-related falls with demographic characteristics and geriatric syndromes were examined using logistic regression models. MAIN OUTCOME MEASURES Potential risk factors for toileting-related falls. RESULTS This study included 419 older patients with a mean age of 73.8±9.7 years. Among 60 (14.3%) patients with toileting-related falls (mean age: 78.8±9.2 years), 63.3% of toileting-related falls, mainly occurred between 00:00 and 05:59 hours, compared with 17.3% of non-toileting-related falls, which primarily occurred during the daytime. The rate of recurrent falls (35%) was significantly higher in the toileting-related falls group than in the non-toileting-related falls group (21.2%) (p=0.02). Logistic regression showed that visual impairment (OR 2.7, 95% CI 1.1 to 7.1), cognitive impairment (OR 3.3, 95% CI 1.3 to 8.4), gait instability (OR 3.1, 95% CI 1.1 to 8.8) and urinary incontinence (OR 3.4, 95% CI 1.2 to 9.9) were strongly associated with toileting-related falls. Twenty-three (38.3%) patients in the toileting-related falls group had moderate and severe injuries, compared with 71.7% in the non-toileting-related falls group (p<0.05). CONCLUSIONS This study revealed that patients who reported toileting-related falls were more likely to have cognitive impairment, urinary incontinence, gait instability, visual impairment than patients who fell during other activities. Social and healthcare professionals should prioritise the management of toileting activities in older patients and provide targeted interventions to those in the high-risk group.
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Affiliation(s)
- Min Zou
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Lu
- Emergency Department, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijun Jiang
- Department of Pharmaceutics, Shanghai Pharmaceutical School, Shanghai, China
| | - Ping Liu
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bingjie Tian
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuqi Liang
- School of Nursing, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - XiaoLing Wang
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Liping Jiang
- Department of Nursing, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Kavi KS, Gall NP. Trauma and syncope: looking beyond the injury. Trauma Surg Acute Care Open 2023; 8:e001036. [PMID: 36744295 PMCID: PMC9896213 DOI: 10.1136/tsaco-2022-001036] [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: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
Background 42% of the population experience syncope by the age of 70, accounting for up to 6% of hospital admissions that frequently present as falls. The etiologies of some falls are benign, and others, such as cardiac syncope, are associated with a greater mortality and must be identified. Methods This review article aims to bridge the literature gap by providing a comprehensive practice review and critical summary of the current syncope guidance relating to the trauma patient. Results The National Institute for Health and Care Excellence, the American College of Cardiology, and European Society of Cardiology published syncope risk stratification guidance. The inclusion of certain high-risk features represented in all three guidelines suggests their significance to identify cardiac syncope including heart failure, abnormal vital signs, syncope during exercise with little to no prodrome, family history of sudden cardiac death, and ECG abnormalities. Of 11 syncope risk stratification scoring systems based on these guidelines, only 2 are externally validated in the emergency department, neither of which are validated for major trauma use. Adherence to thorough history-taking, examination, orthostatic blood pressure recording, and an ECG can diagnose the cause of syncope in up to 50% of patients. ECG findings are 95% to 98% sensitive in the detection of serious adverse outcomes after cardiac syncope and should form part of a standardized syncope trauma assessment. Routine blood testing in trauma is often performed despite evidence that it is neither useful nor cost effective, where the screening of cardiac enzymes and D-dimer rarely influences management. Discussion In the absence of a gold-standard clinical test to identify the cause of a syncopal episode, standardized syncope guidelines as described in this review could be incorporated into trauma protocols to analyze high-risk etiologies, improve diagnostic accuracy, reduce unnecessary investigations, and develop an effective and safer management strategy.
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Affiliation(s)
- Kieran S Kavi
- Department of Emergency Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicholas P Gall
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Lee JS, Khan AD, Quinn CM, Colborn K, Patel DC, Barmparas G, Margulies DR, Waller CJ, Kallies KJ, Fitzsimmons AJ, Kothari SN, Raines AR, Mahnken H, Dunn J, Zier L, McIntyre RC, Urban S, Coleman JR, Campion EM, Burlew CC, Schroeppel TJ. Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study. Am J Surg 2022; 224:1374-1379. [PMID: 35940931 DOI: 10.1016/j.amjsurg.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.
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Affiliation(s)
- Janet S Lee
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Abid D Khan
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL, USA.
| | - Christopher M Quinn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Deven C Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Alec J Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Shanu N Kothari
- Department of General Surgery, Prisma Health, Greenville, SC, USA.
| | - Alexander R Raines
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Heidi Mahnken
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Julie Dunn
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Linda Zier
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Robert C McIntyre
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Shane Urban
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Julia R Coleman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Clay C Burlew
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Thomas J Schroeppel
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
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O'Driscoll CS, Condell R, O'Sullivan D, Davey M, Kearns S, Murphy CG. Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative. Cureus 2022; 14:e30880. [DOI: 10.7759/cureus.30880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
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Gallaher J, Stone L, Marquart G, Freeman C, Zonies D. Do I really need this transthoracic ECHO? An over-utilized test in trauma and surgical intensive care units. Injury 2022; 53:1631-1636. [PMID: 34996627 DOI: 10.1016/j.injury.2021.12.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/03/2021] [Accepted: 12/23/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Clinical use of transthoracic echocardiogram (TTE) in intensive care units (ICU) has dramatically increased without clear guidance on validated assessment indications, appropriateness, and patient value. METHODS A retrospective analysis of consecutive TTEs performed among patients admitted to a tertiary trauma/surgical ICU over 2.5 years was performed. A bivariate analysis and Poisson regression was used to compare patients who received a TTE. Sensitivity analysis was performed to assess patient factors that predict change in management based on TTE. An abnormal exam was defined as having at least one of the following: ejection fraction < 55%, wall motion, pericardial effusion, pericardial effusion, or other significant abnormality including filling defect. The effect on management was derived from clinical course. We hypothesize that these studies are usually normal and rarely lead to changes in clinical management. RESULTS 912 TTEs were performed in 806 patients. The median age was 68 years (IQR 57, 77) and 63.5% were male. Syncope (21.7%) or hypotension/hypovolemia (20.5%) were the most common indications for a TTE. In total, 39.4% TTEs were abnormal and only 7.6% resulted in a change in management. Predictive factors associated with an abnormal exam included: age >50, serum troponin ≥0.1 ng/ml, abnormal ECG, and clinical suspicion of heart failure or acute myocardial infarction. A troponin cutoff level <0.25 ng/mL was the most reliable factor to predict no change in management after TTE with a negative predictive value of 94.3% (95% CI 93.1, 95.3). CONCLUSION TTE is commonly used for patient assessment in critically ill surgical patients but the majority of exams are normal without change in clinical management. Certain patient factors, such as troponin level, may help distinguish which patients would benefit from this diagnostic test. Given the considerable cost associated with TTE and the minimal effect on management, guidelines on appropriate use would provide improved patient value.
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Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Lucas Stone
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Grant Marquart
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Christopher Freeman
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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