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Nanah A, Abdeljaleel F, Matsubara JK, Garcia MVF. Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions. J Intensive Care Med 2024:8850666241275041. [PMID: 39150325 DOI: 10.1177/08850666241275041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation. METHODS A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses. RESULTS 39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01). CONCLUSION The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.
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Affiliation(s)
- Abdelrahman Nanah
- Cleveland Clinic Foundation, Fairview Hospital, Cleveland, Ohio, USA
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Sobeeh FG, Eldayem YBA, Khalifa HK. Validity of different scoring systems in prediction of intensive care unit admission and mortality in acute organophosphate poisoning. Toxicol Res (Camb) 2024; 13:tfae107. [PMID: 39021369 PMCID: PMC11249962 DOI: 10.1093/toxres/tfae107] [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: 04/15/2024] [Revised: 06/12/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024] Open
Abstract
Background Organophosphate compounds (OPCs) pose significant health risks, especially in developing countries with limited resources. Predicting outcomes in OPCs poisoning is crucial for guiding clinical management and reducing mortality rates. The aim of this study to evaluate the validity of different scoring systems Rapid Emergency Medicine Score, Multiple Organ Dysfunction Score, Acute Physiology and Chronic Health Evaluation Score, and Poison Severity Score in prediction of intensive care unit (ICU) admission and mortality of acute OPCs poisoning patients. Methods A cross-sectional study was conducted on 103 patients admitted to Xx Poison Control Center between May 2022 and June 2023. Scoring systems were applied at admission, and their performance in predicting the need for ICU admission and mortality was evaluated using receiver operating characteristic (ROC) curve analysis. Results Most patients survived (92.2%). Only 13.6% of the patients required ICU admission. Significant differences in median scores were observed between survivors and non-survivors and between patients requiring ICU admission and those who did not. Multiple Organ Dysfunction Score exhibited the highest discriminatory power for predicting both ICU admission (AUC = 0.983) and mortality (AUC = 0.999). Conclusion The findings highlight the importance of utilizing scoring systems, particularly Multiple organ dysfunction score, for prediction of poor outcomes of acute OPCs poisoning.
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Affiliation(s)
- Fatma G Sobeeh
- Lecturer of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Tanta University, El-Gash st. Medical Campus The Faculty of Medicine, Tanta, 31527, Egypt
| | - Yara B Abd Eldayem
- Lecturer of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Tanta University, El-Gash st. Medical Campus The Faculty of Medicine, Tanta, 31527, Egypt
| | - Heba K Khalifa
- Assistant Professor of Forensic Medicine & Clinical Toxicology, Faculty of Medicine, Tanta University, El-Gash st. Medical Campus The Faculty of Medicine, Tanta, 31527, Egypt
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Lashin HI, Sobeeh FG, Sobh ZK. Development and validation of a nomogram for predicting mechanical ventilation need among acutely intoxicated patients with impaired consciousness. Hum Exp Toxicol 2024; 43:9603271241267214. [PMID: 39095935 DOI: 10.1177/09603271241267214] [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: 08/04/2024]
Abstract
BACKGROUND A considerable portion of acutely intoxicated patients is presented with impaired consciousness. Early identification of those patients who require advanced medical care, such as mechanical ventilation (MV), can improve their prognosis. METHODS This study included 330 acutely intoxicated patients who were presented with impaired consciousness and admitted to Tanta University Poison Control Center, Egypt, in the period from January 2021 to December 2023. Patients were enrolled in derivation (257 patients) and validation (73 patients) cohorts. Patients' data were analyzed to develop and validate a predictive nomogram to determine the probability of MV need in acutely intoxicated patients. RESULTS Significant predictors for MV need were mean arterial blood pressure (OR = 0.96, p = .014), PaO2 (OR = 0.96, p = .001), pH (OR = 0.00, p < . 001), and glucose/potassium ratio (OR = 1.59, p = .030). These four parameters were used to formulate a bedside nomogram. Receiver-operating characteristic (ROC) analysis for the proposed nomogram shows that area under the curve (AUC) = 95.7%, accuracy = 93.4%, sensitivity = 88.9%, and specificity = 95.1%. The internal validation for the developed nomogram was assessed using a bootstrapping method and calibration curve. Regarding external validation, AUCs for the developed nomogram probability was 96.5%, and for predicted probability using the developed nomogram was 97.8%. CONCLUSION The current study provides a validated nomogram that could be used as a reliable tool for the accurate prediction of MV need among acutely intoxicated patients with impaired consciousness. It could assist in the early identification of patients who will require MV, especially in low-income countries with limited resources.
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Affiliation(s)
- Heba Ibrahim Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Fatma Gaber Sobeeh
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Zahraa Khalifa Sobh
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Sagah GA, Elmansy AM. Comparison of different scores as predictors of mechanical ventilation and intensive care unit admission in acute theophylline poisoning. Toxicol Res (Camb) 2023; 12:990-997. [PMID: 37915483 PMCID: PMC10615812 DOI: 10.1093/toxres/tfad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/06/2023] [Accepted: 09/15/2023] [Indexed: 11/03/2023] Open
Abstract
Background Theophylline is commonly used to control respiratory diseases, especially in developing countries. Theophylline has a narrowed therapeutic index, and its toxicity is associated with morbidity and mortality. Physicians should be aware of the early prediction of the need for intensive care unit admission (ICU) and mechanical ventilation (MV). Aim This study aimed to assess the power of the Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS) and Simple Clinical Score (SCS) in predicting the need for ICU admission and/or MV in acute theophylline-poisoned patients. Patients and methods This cross-sectional study included 58 patients with acute theophylline poisoning who were admitted to our Poison Control Center from the 1st of July 2022 to the 31st of January 2023. The REMS, MEWS and SCS were calculated for all patients on arrival at the hospital. The area under the curve (AUC) and receiver operating characteristics were tested to compare scores. Results The median values of all studied scores were significantly high among patients who needed MV and/or ICU admission. The AUC of SCS was >0.9, with a sensitivity of 92.9% and specificity of 90.9% for the prediction of ICU admission. Meanwhile, MEWS was an excellent predictor of the need for MV (AUC = 0.996, 95% CI = 0.983-1.000). Conclusions We recommend using SCS as an early predictor for ICU admission in acute theophylline-poisoned patients. However, MEWS could effectively predict MV requirements in acute theophylline-poisoned patients.
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Affiliation(s)
- Ghada Attia Sagah
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical collages complex, 6 th Floor, Al-Geish Street, Tanta University, Tanta, Elgharbya 31527, Egypt
| | - Alshaimma Mahmoud Elmansy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical collages complex, 6 th Floor, Al-Geish Street, Tanta University, Tanta, Elgharbya 31527, Egypt
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Lashin HI, Sharif AF. Evaluation of various scoring systems as predictors of the need for intensive care unit admission and other adverse outcomes among patients with acute clozapine poisoning. Toxicol Res (Camb) 2023; 12:468-479. [PMID: 37397925 PMCID: PMC10311143 DOI: 10.1093/toxres/tfad029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/25/2023] [Accepted: 04/06/2023] [Indexed: 07/04/2023] Open
Abstract
Acute clozapine poisoning (ACP) is frequently reported worldwide. We evaluated the efficacy of the Poison Severity Score (PSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS) as predictors for intensive care unit (ICU) admission, mechanical ventilation (MV), mortality, and length of hospital stay in patients with ACP. A retrospective cohort study was conducted using records of patients diagnosed with ACP from January 2017 to June 2022 and admitted to an Egyptian poison control center. Analyzing 156 records showed that all assessed scores were significant predictors of the studied outcomes. The PSS and APACHE II score showed the highest area under the curve (AUC) as ICU admission predictors with insignificant variations. The APACHE II score showed the best discriminatory power in predicting MV and mortality. Nevertheless, MEWS exhibited the highest odds ratio (OR) as an ICU predictor (OR = 2.39, and 95% confidence interval = 1.86-3.27) and as a mortality predictor (OR = 1.98, and 95% confidence interval = 1.16-4.41). REMS and MEWS were better predictors of length of hospital stay compared with the APACHE II score. The simpler, lab-independent nature and the comparable discrimination but higher odds ratio of MEWS compared with APACHE II score justify MEWS' superior utility as an outcome predictor in ACP. We recommend using either the APACHE II score or MEWS, depending on the availability of laboratory investigations, resources, and the case's urgency. Otherwise, the MEWS is a substantially feasible, economical, and bedside alternative outcome predictor in ACP.
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Affiliation(s)
- Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asmaa F Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Abd Elghany SA, Lashin HI, El-Sarnagawy GN, Oreby MM, Soliman E. Development and validation of a novel poisoning agitation-sedation score for predicting the need for endotracheal intubation and mechanical ventilation in acutely poisoned patients with disturbed consciousness. Hum Exp Toxicol 2023; 42:9603271231222253. [PMID: 38105648 DOI: 10.1177/09603271231222253] [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: 12/19/2023]
Abstract
BACKGROUND Accurate assessment of disturbed consciousness level (DCL) is crucial for predicting acutely poisoned patients' outcomes. AIM Development of a novel Poisoning Agitation-Sedation Score (PASS) to predict the need for endotracheal intubation (ETI) and mechanical ventilation (MV) in acutely poisoned patients with DCL. Validation of the proposed score on a new set of acutely poisoned patients with DCL. METHODS This study was conducted on 187 acutely poisoned patients with DCL admitted to hospital from June 2020 to November 2021 (Derivation cohort). Patients' demographics, toxicological data, neurological examination, calculation of the Glasgow Coma Scale (GCS), Full Outline of Unresponsiveness (FOUR) score, Richmond Agitation-Sedation Scale (RASS), and outcomes were gathered for developing a new score. The proposed score was externally validated on 100 acutely poisoned patients with DCL (Validation cohort). RESULTS The PASS assessing sedation consists of FOUR (reflexes and respiration) and GCS (motor) and provides a significantly excellent predictive power (AUC = 0.975) at a cutoff ≤9 with 100% sensitivity and 92.11% specificity for predicting the need for ETI and MV in sedated patients. Additionally, adding RASS (agitation) to the previous model exhibits significantly good predictive power (AUC = 0.893), 90.32% sensitivity, and 73.68% specificity at a cutoff ≤14 for predicting the need for ETI and MV in disturbed consciousness patients with agitation. CONCLUSION The proposed PASS could be an excellent, valid and feasible tool to predict the need for ETI and MV in acutely poisoned disturbed consciousness patients with or without agitation.
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Affiliation(s)
- Soha A Abd Elghany
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ghada N El-Sarnagawy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Merfat M Oreby
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Eman Soliman
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Ghaffarzad A, Vahed N, Shams Vahdati S, Ala A, Jalali M. The Accuracy of Rapid Emergency Medicine Score in Predicting Mortality in Non-Surgical Patients: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:83-94. [PMID: 35291430 PMCID: PMC8919305 DOI: 10.30476/ijms.2021.86079.1579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/24/2020] [Accepted: 10/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency department (ED) physicians often need to quickly assess patients and determine vital signs to prioritize them by the severity of their condition and make optimal treatment decisions. Effective triage requires optimal scoring systems to accelerate and positively influence the treatment of trauma cases. To this end, a variety of scoring systems have been developed to enable rapid assessment of ED patients. The present systematic review and meta-analysis aimed to investigate the accuracy of the rapid emergency medicine score (REMS) system in predicting the mortality rate in non-surgical ED patients. METHODS A systematic search of articles published between 1990 and 2020 was conducted using various scientific databases (Medline, Embase, Scopus, Web of Science, ProQuest, Cochrane Library, IranDOC, Magiran, and Scientific Information Database). Both cross-sectional and cohort studies assessing the REMS system to predict mortality in ED settings were considered. Two reviewers appraised the selected articles independently using the National Institutes of Health (NIH) quality assessment tool. The random-effects model was used for meta-analysis. I2 index and Q statistic were used to examine heterogeneity between the articles. RESULTS The search resulted in 1,310 hits from which, 29 articles were eventually selected. Out of these, for 25 articles, the area under the curve value of REMS ranged from 0.52 to 0.986. The predictive power of REMS for the in-hospital mortality rate was high in 19 articles (67.85%) and low in nine articles (32.15%). CONCLUSION The results showed that the REMS system is an effective tool to predict mortality in non-surgical patients presented to the ED. However, further evidence using high-quality design studies is required to substantiate our findings.
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Affiliation(s)
- Amir Ghaffarzad
- Emergency Medicine Research Team, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nafiseh Vahed
- Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Affiliated Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Shams Vahdati
- Emergency Medicine Research Team, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Ala
- Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Affiliated Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Jalali
- Emergency Medicine Research Team, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Elgazzar FM, Afifi AM, Shama MAE, Askary AE, El-Sarnagawy GN. Development of a risk prediction nomogram for disposition of acute toxic exposure patients to intensive care unit. Basic Clin Pharmacol Toxicol 2021; 129:256-267. [PMID: 34117718 DOI: 10.1111/bcpt.13619] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022]
Abstract
Early risk stratification of acutely poisoned patients is essential to identify patients at high risk of intensive care unit (ICU) admission. We aimed to develop a prognostic model and risk-stratification nomogram based on the readily accessible clinical and laboratory predictors on admission for the probability of ICU admission in acutely poisoned patients. This retrospective cohort study included adult patients with acute toxic exposure to a drug or a chemical substance. Patients' demographic, toxicologic, clinical and laboratory data were collected. Among the 1260 eligible patients, 180 (14.3%) were admitted to the ICU. We developed a generalized prognostic model for predicting ICU admission in patients with acute poisoning. The predictors included the Glasgow coma scale, oxygen saturation, diastolic blood pressure, respiratory rate and blood bicarbonate concentration. The model displayed excellent discrimination and calibration (optimistic-adjusted area under the curve = 0.924 and optimistic-adjusted Hosmer and Lemeshow test = 0.922, respectively) when internally validated. Additionally, we developed prognostic models that determine ICU admission in patients with specific poisonings. Furthermore, we constructed risk-stratification nomograms that rank the probability of ICU admission in these patients. The developed risk-stratification nomograms help decision-making regarding ICU admission in acute poisonings. Future external validation in independent cohorts is necessary before clinical application.
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Affiliation(s)
- Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmed M Afifi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Mohamed Abd Elhady Shama
- Emergency Medicine and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmad El Askary
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Ghada N El-Sarnagawy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Buswell L, Hayes A, Baombe J. BET 2: Predicting the need for endotracheal intubation in poisoned patients. Emerg Med J 2020; 36:573-575. [PMID: 31427477 DOI: 10.1136/emermed-2019-208927.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2019] [Indexed: 11/04/2022]
Abstract
A short cut review of the literature was carried out to establish whether any risk factors would predict the need for endotracheal intubation in undifferentiated adult patients presenting with poisoning/overdose with unknown substance. Five papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that further robust studies of large cohorts are needed to answer this difficult question.
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The Rapid Emergency Medicine Score: A Critical Appraisal of Its Measurement Properties and Applicability to the Air Retrieval Environment. Air Med J 2019; 38:154-160. [PMID: 31122578 DOI: 10.1016/j.amj.2019.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/14/2018] [Accepted: 02/12/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The Rapid Emergency Medicine Score (REMS) was designed to predict in-hospital mortality using variables that are available in the prehospital setting. The objective of this article is to critically appraise the development and summarize the evidence regarding the measurement properties (sensitivity, reliability and validity) of the REMS. METHODS A literature search was performed identifying all studies describing the REMS. The original validation study was critically appraised for its development. All other studies that reported any measurement properties of the REMS were also appraised for evidence of calibration, reliability, and validity. RESULTS In total, 26 studies reported on the measurement properties of the REMS. Overall, the REMS was developed with robust methodology and has good sensibility with adequate content and face validity. It is easy to understand and feasible to be calculated within minutes of patient assessment. The REMS has the necessary measurement properties to be both a predictive and evaluative clinical index to measure prehospital severity of illness; however, no studies have adequately addressed the intra or inter-rater reliability of the score. CONCLUSIONS There is evidence to support the use of the REMS as a predictive or evaluative instrument. In most studies, it performed as well or better than other illness severity scores in predicting mortality.
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