Characteristics and Outcomes Associated With Emergent Rectal Foreign Body Management: A Retrospective Cohort Analysis

Background Bedside management and outcomes of rectal foreign bodies remain challenging due to the presentation and complexity of the inserted objects. Injuries, such as perforation of the colon and rectum, are among the most commonly reported complications. However, prior studies are unclear regarding the setting in which the complication rates may be minimized. This study aimed to assess whether there was a statistically significant difference among the various extraction methods with regard to complications in the emergency department and operating room. Materials and methods This was a retrospective study of all cases of rectal foreign bodies that were removed in the emergency department at a large county hospital between 1/1/2010 and 12/31/2020. Patients included in this study were adults who were evaluated and treated in the emergency department. Results A total of 78 patients were included in the final analysis. More than half (51.3%, n=40) of the patients were successfully treated in the emergency department. Compared with the emergency department, patients in the operating room were more likely to undergo exploratory laparotomy and colectomy (0% vs. 31.6%, p<0.0001), undergo general anesthesia (84.2% vs. 0%, p<0.0001), have higher complication rates (21% vs. 0%, p=0.0021), and have a longer hospital length of stay (median=1 vs. 0, p<0.0001). Conclusion This study revealed a >50% success rate of rectal foreign body removal in the emergency department without any reported complications. To improve the success rate of bedside retrieval and decrease complications, physicians need to be vigilant, communicative, and compassionate about their evaluations and clinical methodology.

The Effect of Glycemic Control on Morbidity and Mortality in Critically Ill COVID-19 Patients

Background COVID-19 infection has caused a global pandemic affecting a group of patients with chronic conditions including diabetes with exacerbating insulin resistance and hyperglycemia. Investigators noted that pre-existing diabetes and newly diagnosed diabetes are associated with an increased risk of all-cause mortality in hospitalized patients with COVID-19 infection. Aim To evaluate the relationship between ICU patients infected with COVID-19 and mortality among those with high versus low glucose levels. Methods This is a retrospective study of critically ill adult patients infected with COVID-19 who were admitted to the ICU from April 5, 2020, to October 14, 2020. The participants were from San Bernardino County which is a diverse and underserved community. Overall, 84 patients were included in the final analysis. The average age was 59.67 (standard deviation=15.55) with 59.5% being males. Overall mortality was 44.1%. Results Around one-fifth of patients had glucose under control as measured by peak glucose level of <180 mg/dL during hospital stay. A statistically significant association was seen between tighter serum glucose control and mortality (p=0.0354). Patients with serum glucose maintained <180 mg/dL were associated with significantly lower mortality than their counterparts (22.2% vs. 50%). Conclusions This study suggests that maintaining a tighter control of the glycemic index in critically ill COVID-19 patients will improve morbidity and mortality.

Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Emergent surgical interventions in noncritical traumatic long bone fractures and lactate monitoring: a retrospective cohort study

Serum lactate levels have been recommended as a standard in guiding resuscitation and management of post-traumatic orthopedic injuries. Studies have suggested an increased incidence of postoperative complications in trauma patients with injury severity scores (ISSs) greater than 18. However, in trauma patients without an elevated ISS, the role of lactate in guiding operative timing has not been explored. This study considers the role of lactate measurement with respect to surgical timing and predicting postoperative complications in trauma patients with long bone fractures and an ISS less than 16.

Materials and methods

A total of 164 patients, ages 18 and above with long bone fractures and ISS less than 16 were sampled in the last 5 years. Demographic data was ascertained. Patients were placed into two cohorts with a serum preoperative lactate greater than or equal to 2.0 mmol/l and a serum preoperative lactate less than 2.0 mmol/l. Key endpoints included hospital mortality, length of hospitalization (LOH), discharge designation, and postoperative complications.

Results

A total of 148 patients had a lactate level less than 2.0 mmol/l and 16 had a lactate greater than or equal to 2.0 mmol/l. There was no significant difference in demographics between these two preoperative lactate groups. There was no statistical difference when considering mortality, discharge designation, LOH, and postoperative complications.

Conclusion

Lactate levels assist providers in guide resuscitative efforts in trauma patients. However, this study finds that preoperative lactate measurements and efforts made to normalize lactate level are not correlated with mortality, LOH, and postoperative complications in trauma patients with an ISS less than 16. This study does not support preoperative lactate normalization in guiding surgical timing.

P13BP, a Calpain-2-Mediated Breakdown Product of PTPN13, Is a Novel Blood Biomarker for Traumatic Brain Injury

Biomarkers play an increasing role in medicinal biology. They are used for diagnosis, management, drug target identification, drug responses, and disease prognosis. We have discovered that calpain-1 and calpain-2 play opposite functions in neurodegeneration, with calpain-1 activation being neuroprotective, while prolonged calpain-2 activation is neurodegenerative. This notion has been validated in several mouse models of acute neuronal injury, in particular in mouse models of traumatic brain injury (TBI) and repeated concussions. We have identified a selective substrate of calpain-2, the tyrosine phosphatase, PTPN13, which is cleaved in brain after TBI. One of the fragments generated by calpain-2, referred to as P13BP, is also found in the blood after TBI both in mice and humans. In humans, P13BP blood levels are significantly correlated with the severity of TBI, as measured by Glasgow Coma Scale scores and loss of consciousness. The results indicate that P13BP represents a novel blood biomarker for TBI.

Depression and anxiety prevalence in nursing staff during the COVID-19 pandemic

This article reviews a study to determine the effects of COVID-19 on the rate of depression and anxiety in nurses and to identify potential strategies that nurse leaders can implement to reduce depression and anxiety in their staff.

Spontaneous Rupture of Empyema Necessitans in the Emergency Department

An empyema necessitans is a rare complication of a collection of purulent material in the pleural space that spreads outside of the pleural cavity and involves the soft tissues of the chest wall. Due to compression forces created by the size of the collection of empyema in the chest cavity, patients are usually symptomatic and present with severe dyspnea. Chest X-ray or ultrasound of the chest cavity are the ideal screening tools to visualize the empyema and followed by computerized tomography scan of the chest to confirm the presence and extent of the pathology. In rare occasions, the empyema can rupture spontaneously, which may lead to critical situation requiring emergent intervention. We report the case of a 72-year-old male who presented to the emergency department with severe dyspnea and was diagnosed with empyema necesitans. During the initial management of the case, the empyema necessitans ruptured spontaneously and required emergent interventions to stabilize the patient.

Prehospital Trauma Care in Disasters and Other Mass Casualty Incidents - A Proposal for Hospital-Based Special Medical Response Teams

Current mass casualty incident (MCI) response in the United States calls for rapid deployment of first responders, such as law enforcement, fire, and emergency medical services personnel, to the incident and simultaneous activation of trauma center disaster protocols. Past investigations demonstrated that the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams resulted in improved mortality during routine emergency medical care in Europe and in the combat setting. To date, limited research exists on the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams for civilian MCIs.

We proposed the concept of Special Medical Response Teams, which would rapidly deploy advanced trauma-trained physicians and paramedics to deliver a higher level of medical and surgical care in the prehospital setting during civilian mass casualty incidents.

Underutilization of the Emergency Department During the COVID-19 Pandemic

INTRODUCTION

The novel coronavirus 2019 (COVID-19) pandemic in the United States (US) prompted widespread containment measures such as shelter-in-place (SIP) orders. The goal of our study was to determine whether there was a significant change in overall volume and proportion of emergency department (ED) encounters since SIP measures began.

METHODS

This was a retrospective, observational, cross-sectional study using billing data from January 1, 2017-April 20, 2020. We received data from 141 EDs across 16 states, encompassing a convenience sample of 26,223,438 ED encounters. We used a generalized least squares regression approach to ascertain changes for overall ED encounters, hospital admissions, and New York University ED visit algorithm categories.

RESULTS

ED encounters decreased significantly in the post-SIP period. Overall, there was a 39.6% decrease in ED encounters compared to expected volume in the pre-SIP period. Emergent encounters decreased by 35.8%, while non-emergent encounters decreased by 52.1%. Psychiatric encounters decreased by 30.2%. Encounters related to drugs and alcohol decreased the least, by 9.3% and 27.5%, respectively.

CONCLUSION

There was a significant overall reduction in ED utilization in the post-SIP period. There was a greater reduction in lower acuity encounters than higher acuity encounters. Of all subtypes of ED encounters, substance abuse- and alcohol-related encounters reduced the least, and injury-related encounters reduced the most.

An Interesting Civilian Case of Complex Maxillofacial Trauma Due to Target Fragmentation Following Bullet Impact and Review of the Branches of the Maxillary Artery

Serious morbidity and mortality for the operator and bystanders are associated with a lack of knowledge and failure to utilize appropriately manufactured targets. The management of firearm-related facial trauma is challenging and requires rapid intervention from a multidisciplinary team. We present a case of penetrating facial trauma secondary to the fragmentation of a homemade target. We highlight how firearm operators can optimize safety by matching ballistics with target selection and review pertinent vascular structures, including the terminal branches of the external carotid artery and branches of the maxillary artery. This case demonstrates that trauma physicians must be well-versed with complex maxillofacial anatomy and multimodal approaches to hemostasis.

The Effect of Physician-Led Enhanced Care Teams in Prehospital Trauma Resuscitation

Trauma is the leading cause of morbidity and mortality for those under 45 years of age in the United States with half of the deaths in trauma being attributed to hemorrhagic shock. The use of enhanced care teams (ECTs) that include physicians in selective prehospital settings has allowed the delivery of advanced critical care interventions in the field. We present a unique case where a young driver involved in a motor vehicle accident was trapped under the weight of his vehicle, causing extended extrication time. An ECT from the closest trauma center was able to deliver massive transfusion and definitive airway care while the patient was being extricated. While previous literature regarding the benefit of ECTs has been debated, this case suggests a unique niche where rapid deployment of an ECT to the scene made a pronounced difference in survival of the patient.

Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population

Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain.

This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value<0.05 was considered to be statistically significant.

A total of 368 patients were included in the final analysis. The average age was 52.9 ± 23.1 years, and the average weight was 80.4 ± 22.2 kg. There was a statistically significant reduction in the pain score (9.13 ± 1.28 vs 3.7 ± 3.4, delta=5.43 ± 3.38, p<0.0001). Additionally, there was a statistically significant change in systolic blood pressure (143.42 ± 27.01 vs 145.65 ± 26.26, delta=2.22 ± 21.1, p=0.044), pulse (88.06 ± 18 vs 84.64 ± 15.92, delta= -3.42 ± 12.12, p<0.0001), and respiratory rate (19.04 ± 3.59 vs 17.74 ± 3.06, delta=-1.3 ± 2.96, p<0.0001).

The current study suggested that paramedics are capable of safely identifying the appropriate patients for the administration of sub-dissociative doses of ketamine in the prehospital setting. Furthermore, the current study suggested that ketamine may be an effective analgesic in a select group of adult trauma patients.

Objective Characterization of Opiate-Induced Chest Wall Rigidity

Introduction

Opiate-induced chest wall rigidity is a syndrome that largely goes unrecognized. To date, no study has presented significant objective data to better understand this syndrome.

Objective

The aim of this study was to explore the correlation between the dosage of opiates and the incidence of chest wall rigidity, ventilatory changes, and effects of naloxone administration.

Methods

A total of eight patients were identified as having episodes of chest wall rigidity, with half of the population being females, with an average age of 54.8 ± 9 years. Physiological changes, ventilator data, vitals, and opiate dosage prior to chest wall rigidity episodes and after reversal with naloxone administration were analyzed using the Wilcoxon rank sum test for statistical significance.

Results

Significant changes were observed in dynamic wall compliance without positive end-expiratory pressure (PEEP) (pre-median=5.13; post-median=52.03; p=0.0078), dynamic wall compliance with PEEP (pre-median=6.13; post-median=72.36; p=0.0078), tidal volume (pre-median=110.5; post-median=1006; p=0.0078), and ventilator airflow (pre-median=0; post-median=75; p=0.0078). However, no statistically significant changes were detected in end tidal CO₂ (pre-median=36; post-median=37.5; p=0.4219), respiratory rate (pre-median=9; post-median=10.5; p=0.7188), or peak airway pressure (pre-median=17; post-median=21.5; p=0.4063). Additionally, there is a statistically significant correlation between morphine equivalent potency dosing within 24 hours and the change in tidal volume (r=0.8237; p=0.0439).

Conclusions

Our study is the first to demonstrate significant objective data on the ventilatory responses seen with opiate-induced chest wall rigidity. These findings may assist clinicians in better understanding the presentation and management of chest wall rigidity.

Increasing Chlamydia and Gonorrhea Infections among Female Juveniles: The Need for Collaboration to Improve Treatment

Background: Youth in juvenile detention centers are at a high risk for sexually transmitted disease (STD). The current study assesses the trends of chlamydia and gonorrhea (GC) infections and treatment among females within a single county’s juvenile correctional facilities.

Methods: This is a retrospective review of aggregate data of female adolescents between 12 and 18 years old who underwent STD screening from 2009 to 2016 in San Bernardino County.

Results: Chlamydia infections among adolescent females increased from 11.8% in 2009 to 17.0% in 2016 (p = 0.0002), and GC infections increased from 1.3% in 2009 to 6.0% in 2016 (p < 0.0001). Treatment rates of chlamydia were stable, ranging from 66.7% to 70.8% of positive female adolescents were treated between 2009 and 2016 (p=0.1752). The treatment rate for GC increased from 33% in 2009 to 78.3% in 2016, but annual trends were not statistically significant (p=0.8419).

Conclusions: Chlamydia and GC infections among female adolescents discovered during routine screening upon booking into a county juvenile detention system increased over the study time period. Effective collaboration between public health and various community organizations is needed to improve awareness and prevention of STDs amongst at-risk adolescents.

Management of Traumatic Uterine Rupture in Blunt Abdominal Trauma: A Case Report and Literature Review

A 27-year-old female with an 18-week pregnancy was involved in a high impact motor vehicle accident due to which she suffered a uterine rupture secondary to blunt abdominal trauma. Traumatic uterine rupture may result from blunt abdominal traumas such as those that occur during motor vehicle accidents. Prompt diagnosis is necessary to treat this complication given its quick onset and progression, and prevent potential life-threatening complications to mother and fetus. Here, we present a unique case of uterine rupture that was surgically repaired, allowing for the continuation of pregnancy.

Succinylcholine Administration and Resultant Pulseless Ventricular Tachycardia: A Case Report of Communication Breakdown During an Emergent Intubation

Poor communication continues to be one of the leading root causes of sentinel events in the United States annually. This case report documents a miscommunication that occurred during the management of a patient with Guillain-Barré syndrome (GBS) and acute respiratory failure requiring emergent intubation, which resulted in a transient hyperkalemia and subsequent cardiac arrest.

Evaluation of the United States Preventative Services Task Force Screening Guidelines for Breast Cancer in a Hispanic Underserved Population

There are several major breast cancer guidelines that have been promoted by various health organizations. Arrowhead Regional Medical Center (ARMC) Family Health Centers adopted the current guideline by the U.S. Preventive Services Task Force (USPSTF), which recommends breast cancer screening with mammograms starting at age 50 for low-risk women. This study evaluates the effectiveness of this screening guideline in the selected Hispanic underserved population in San Bernardino, California (CA). This is a retrospective chart review study. Data were reviewed for any female with the confirmed diagnosis of breast cancer at the Family Health Centers between 2009 and 2018. The current study showed that 25% (40 of 160) of women diagnosed with breast cancer in this selected population were less than 50 years old. This finding suggests that high vigilance in breast cancer screening may be necessary in this population.

UNIFIED: Understanding New Information from Emergency Departments Involved in the San Bernardino Terrorist Attack

INTRODUCTION

Emergency departments (ED) are on the front line for treating victims of multi-casualty incidents. The primary objective of this study was to gather and detail the common experiences from those hospital-based health professionals directly involved in the response to the San Bernardino terrorism attack on December 2, 2015. Secondary objectives included gathering information on experiences participants found were best practices.

METHODS

We undertook a qualitative study using Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines by performing semi-structured interviews with physicians, nurses, and incident management staff from multiple institutions responding to the San Bernardino terrorist attack. We coded transcripts using qualitative analysis techniques and we delineated and agreed upon a refined list with code definitions using a negotiated group process. Final themes were developed and analyzed.

RESULTS

A total of 26 interviews were completed; 1172 excerpts were coded and categorized into 66 initial themes. Six final categories of communication, training, unexpected help, process bypassed, personal impact/emotions, and practical advice resulted.

CONCLUSION

Our study provides context regarding the response of healthcare personnel from multiple institutions to a singular terrorist attack in the United States. It elucidates several themes to help other institutions prepare for similar events. Understanding these common experiences provides opportunity to prepare for future incidents and develop questions to study in future events.

Froin's Syndrome Secondary to Traumatic and Infectious Etiology

The protein level in the cerebrospinal fluid (CSF) is an important diagnostic tool and, when abnormal, can provide clinicians with clues to the etiology of a patient’s condition. Froin’s syndrome has been described in previous literature as the combination of xanthochromia, elevated protein, and hypercoagulated CSF. The pathophysiology behind Froin’s syndrome is thought to be due to stagnant CSF causing passive and/or active diffusive processes, resulting in hyperproteinosis and hypercoagulation. We present a case of Froin's syndrome in a patient with cervical spine trauma whose extraordinary level of CSF proteinosis helped raise suspicion for underlying obstructive and infectious etiology.

E-cigarette Blast Injury: Complex Facial Fractures and Pneumocephalus

Electronic cigarettes (also known as e-cigarettes or e-cigs) are becoming a popular method of recreational nicotine use over recent years. The growth of new brands and devices has been outpacing the FDA’s ability to regulate them. As a result, some of these devices fail without warning, most likely from malfunction of the lithium-ion batteries that are in close proximity to volatile compounds within the device. Failures have occurred during both use and storage of the devices or their components. The subsequent injuries from several of these events, including full thickness burns requiring grafting and blast injuries, have been observed at Arrowhead Regional Medical Center, a regional trauma and burn center in southern California. One severe case resulted in several maxillofacial fractures, blurred vision, and pneumocephalus after a device failed catastrophically during use. The patient required close monitoring with serial imaging by neurosurgery in the intensive care unit and multiple procedures by oral maxillofacial surgery to reconstruct his facial bones and soft tissue. Ultimately, the patient recovered with minimal permanent damage, but the potential for further injury or even death was apparent. Cases such as this one are becoming more frequent. It is important to increase awareness of this growing problem for both medical professionals and the general public in order to curb this concerning new trend.

The San Bernardino, California, Terror Attack: Two Emergency Departments' Response

On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims. In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care. MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in management of future MCIs.

Neonatal sympathectomy reduces adult blood pressure and cardiovascular pathology in Y chromosome consomic rats

The hypothesis was tested that the sympathetic nervous system (SNS) developmentally influences circulating testosterone (T), systolic blood pressure (SBP) and cardio-renal pathology in SHR/y animals. A sympathoplegic drug, guanethidine, and an antibody to nerve growth factor were administered to WKY and borderline hypertensive SHR/y male rats (n = 20/group) for the first 3 weeks of life; control groups (n = 20/group) received saline. SBP, serum T and luteinizing hormone (LH) were measured. SBP in the WKY and SHR/y sympathectomy (sympx) groups decreased 10mmHg (p < 0.001) and 50mmHg (p < 0.001), respectively, when compared to their control groups. Serum T levels in the sympx WKY group were lower (p < 0.01) than those in controls, and the rise of T typically observed in SHR/y from weeks 6-8 was delayed in the sympx SHR/y group, similar to the pattern in WKY. Serum LH levels were increased in the sympx WKY group, but not in the SHR/y group. Sympx caused a greater reduction in renal glomerular changes (p < 0.01), coronary artery collagen deposition (p < 0.01) and myocardial fibrosis (p < 0.01) in SHR/y than WKY rats. In conclusion, the SHR Y chromosome has a locus that enhances SNS activity, which can raise SBP and result in renal and cardiovascular tissue damage.