The optimal management of minor head injured patients with brain injury identified by CT imaging is unclear. Some guidelines recommend routine hospital admission of GCS13-15 patients with traumatic ...brain (TBI) injury identified by CT imaging. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED).
To estimate the risk of death, neurosurgery and clinical deterioration minor head injured patients with TBI identified by CT imaging, and assess which factors affect the risk of these outcomes.emermed;34/12/A862-a/F1F1F1Figure 1Risk of neurosurgery stratified by the initial GCS of the study population METHODS: A systematic review and meta-analysis adhering to PRISMA standards of reporting. Four electronic data bases and a range of additional literature were searched using a highly sensitive search strategy. Study selection was performed by 2 independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks of: clinical deterioration, neurosurgery and death. Meta-regression was used to explore between study variation in outcome estimates using study characteristics. Factors assessed by individual studies as affecting the outcomes of interest were recorded and pooled within study risk factor effects were estimated where possible.
4431 studies were identified by the search strategy, of which 123 studies were fully retrieved and 49 primary studies and 5 reviews met the inclusion criteria. The estimated pooled risk of the outcomes of interest were: clinical deterioration 11.7% (95% CI:11.7 to 15.8; neurosurgery 3.5% (95% CI:2.2% to 4.9%); death 1.4% (95% CI:0.8% to 2.2%). A large degree of between study variation in the estimates of the outcomes was identified. Multivariable meta-regression of study characteristics identified that mean age of the study population and mean initial GCS accounted for up to half of the variation in reported study outcomes. Within studies the following factors were found to affect the risk for these adverse outcomes: age; severity of injury; type of injury; initial GCS; anti-coagulation; anti-platelet medication; and injury severity scoring. When univariable within study risk factor effect estimates were pooled patients with isolated subarachnoid haemorrhage had an odds ratio of 0.19 for deterioration compared to other injury types.emermed;34/12/A862-a/F2F2F2Figure 2Meta-regression of study factors predictive of neurosurgery CONCLUSION: Minor head injured patients with brain injury identified by CT imaging have a clinically important risk of serious adverse outcomes. Research has identified the possible factors that affect this risk. However, these factors need to be incorporated into a validated multivariable prognostic model before low-risk patients can be reliably identified clinically and triaged to lower levels of care.emermed;34/12/A862-a/F3F3F3Figure 3PRISMA flow-diagram showing selection of studies for inclusion in the systematic review.
The WHO and National Institute for Health and Care Excellence recommend various triage tools to assist decision-making for patients with suspected COVID-19. We aimed to compare the accuracy of triage ...tools for predicting severe illness in adults presenting to the ED with suspected COVID-19.
We undertook a mixed prospective and retrospective observational cohort study in 70 EDs across the UK. We collected data from people attending with suspected COVID-19 and used presenting data to determine the results of assessment with the WHO algorithm, National Early Warning Score version 2 (NEWS2), CURB-65, CRB-65, Pandemic Modified Early Warning Score (PMEWS) and the swine flu adult hospital pathway (SFAHP). We used 30-day outcome data (death or receipt of respiratory, cardiovascular or renal support) to determine prognostic accuracy for adverse outcome.
We analysed data from 20 891 adults, of whom 4611 (22.1%) died or received organ support (primary outcome), with 2058 (9.9%) receiving organ support and 2553 (12.2%) dying without organ support (secondary outcomes). C-statistics for the primary outcome were: CURB-65 0.75; CRB-65 0.70; PMEWS 0.77; NEWS2 (score) 0.77; NEWS2 (rule) 0.69; SFAHP (6-point rule) 0.70; SFAHP (7-point rule) 0.68; WHO algorithm 0.61. All triage tools showed worse prediction for receipt of organ support and better prediction for death without organ support. At the recommended threshold, PMEWS and the WHO criteria showed good sensitivity (0.97 and 0.95, respectively) at the expense of specificity (0.30 and 0.27, respectively). The NEWS2 score showed similar sensitivity (0.96) and specificity (0.28) when a lower threshold than recommended was used.
CURB-65, PMEWS and the NEWS2 score provide good but not excellent prediction for adverse outcome in suspected COVID-19, and predicted death without organ support better than receipt of organ support. PMEWS, the WHO criteria and NEWS2 (using a lower threshold than usually recommended) provide good sensitivity at the expense of specificity.
ISRCTN56149622.
Tools proposed to triage patient acuity in COVID-19 infection have only been validated in hospital populations. We estimated the accuracy of five risk-stratification tools recommended to predict ...severe illness and compared accuracy to existing clinical decision making in a prehospital setting.
An observational cohort study using linked ambulance service data for patients attended by Emergency Medical Service (EMS) crews in the Yorkshire and Humber region of England between 26 March 2020 and 25 June 2020 was conducted to assess performance of the Pandemic Respiratory Infection Emergency System Triage (PRIEST) tool, National Early Warning Score (NEWS2), WHO algorithm, CRB-65 and Pandemic Medical Early Warning Score (PMEWS) in patients with suspected COVID-19 infection. The primary outcome was death or need for organ support.
Of the 7549 patients in our cohort, 17.6% (95% CI 16.8% to 18.5%) experienced the primary outcome. The NEWS2 (National Early Warning Score, version 2), PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes with a high sensitivity (>0.95) and specificity ranging from 0.3 (NEWS2) to 0.41 (PRIEST tool). The high sensitivity of NEWS2 and PMEWS was achieved by using lower thresholds than previously recommended. On index assessment, 65% of patients were transported to hospital and EMS decision to transfer patients achieved a sensitivity of 0.84 (95% CI 0.83 to 0.85) and specificity of 0.39 (95% CI 0.39 to 0.40).
Use of NEWS2, PMEWS, PRIEST tool and WHO algorithm could improve sensitivity of EMS triage of patients with suspected COVID-19 infection. Use of the PRIEST tool would improve sensitivity of triage without increasing the number of patients conveyed to hospital.
Background 1.4 million patients attend English and Welsh Emergency Departments (ED) annually following head injury. 95% attend with a high level of consciousness, of whom 1% have life-threatening ...traumatic brain injuries (TBI), whilst 7% have TBI on CT imaging. National guidelines were introduced in England and Scotland to improve TBI outcomes and reduce hospital admissions. The impact of these guidelines has not been rigorously assessed. They recommend patients with injuries on CT imaging be admitted to hospital in case they deteriorate. Accurate prediction of deterioration could identify patients safe for discharge from the ED. Aims Assess the impact of national guidelines on deaths and admissions. Develop a prediction model for deterioration in patients with injuries identified by CT imaging. Methods Interrupted time series analyses using national data for England and Scotland were conducted to evaluate guideline impact. A systematic review was completed to identify candidate prognostic factors for deterioration. Multivariable logistic regression was used to develop prognostic models using these factors in an English multi-centre retrospective cohort of patients. Results Guideline impact varied by age group. Associated reductions in hospital admissions and mortality were found in those aged 16-64. In older patients, an increase in TBI mortality was observed, which was unaffected by guideline introduction. A prognostic model and decision rule was developed, using data from a cohort of 1699 patients. It achieved a sensitivity of 99.5% (95% CI: 98.1% to 99.9%) and specificity of 7.4% (95% CI: 6% to 9.1%) to a measure of deterioration encompassing need for admission. Conclusion This first national evaluation of head injury guidelines to use quasi-experimental methods suggests guideline impact varied by age. This first empirically derived prediction model to inform admission decisions suggests a small proportion of patients could be safely discharged from the ED. External validation is required before clinical use.
Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven ...risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa.
An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days.
Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage.
No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.
To assess accuracy of emergency medical service (EMS) telephone triage in identifying patients who need an EMS response and identify factors which affect triage accuracy.
Observational cohort study.
...Emergency telephone triage provided by Yorkshire Ambulance Service (YAS) National Health Service (NHS) Trust.
12 653 adults who contacted EMS telephone triage services provided by YAS between 2 April 2020 and 29 June 2020 assessed by COVID-19 telephone triage pathways were included.
Accuracy of call handler decision to dispatch an ambulance was assessed in terms of death or need for organ support at 30 days from first contact with the telephone triage service.
Callers contacting EMS dispatch services had an 11.1% (1405/12 653) risk of death or needing organ support. In total, 2000/12 653 (16%) of callers did not receive an emergency response and they had a 70/2000 (3.5%) risk of death or organ support. Ambulances were dispatched to 4230 callers (33.4%) who were not conveyed to hospital and did not deteriorate. Multivariable modelling found variables of older age (1 year increase, OR: 1.05, 95% CI: 1.04 to 1.05) and presence of pre-existing respiratory disease (OR: 1.35, 95% CI: 1.13 to 1.60) to be predictors of false positive triage.
Telephone triage can reduce ambulance responses but, with low specificity. A small but significant proportion of patients who do not receive an initial emergency response deteriorated. Research to improve accuracy of EMS telephone triage is needed and, due to limitations of routinely collected data, this is likely to require prospective data collection.
ObjectivesHead injury is a common reason for emergency department (ED) attendance. Around 1% of patients have life-threatening injuries, while 80% of patients are discharged. National guidelines ...(Scottish Intercollegiate Guidelines Network (SIGN)) were introduced in Scotland with the aim of achieving early identification of those with acute intracranial lesions yet safely reducing hospital admissions.This study aims to assess the impact of these guidelines and any effect the national 4-hour ED performance target had on hospital admissions for head injury.SettingAll Scottish hospitals between April 1998 and March 2016.ParticipantsPatients admitted to hospital for head injury or traumatic brain injury (TBI) diagnosed by CT imaging identified using administrative Scottish Information Services Division data. There are 275 hospitals in Scotland. In 2015/2016, there were 571 221 emergency hospital admissions in Scotland.InterventionsThe SIGN head injury guidelines introduced in 2000 and 2009. The 4-hour ED target introduced in 2004.OutcomesThe monthly rate of hospital admissions for head injury and traumatic brain injury.Study designAn interrupted time series analysis.ResultsThe first guideline was associated with a reduction in monthly admissions of 0.14 (95% CI 0.09 to 4.83) per 100 000 population. The 4-hour target was associated with a monthly increase in admissions of 0.13 (95% CI 0.06 to 0.20) per 100 000 population. The second guideline reduced monthly admissions by 0.09 (95% CI−0.13 to −0.05) per 100 000 population. These effects varied between age groups.The guidelines were associated with increased admissions for patients with injuries identified by CT imaging—guideline 1: 0.06 (95% CI 0.004 to 0.12); guideline 2: 0.05 (95% CI 0.04 to 0.06) per 100 000 population.ConclusionIncreased CT imaging of head injured patients recommended by SIGN guidelines reduced hospital admissions. The 4-hour ED target and the increased identification of TBI by CT imaging acted to undermine this effect.
Postmortem ICD interrogation in mode of death classification Nikolaidou, Theodora; Johnson, Miriam J.; Ghosh, Justin M. ...
Journal of cardiovascular electrophysiology,
April 2018, 2018-04-00, 20180401, Letnik:
29, Številka:
4
Journal Article
Recenzirano
Background
The definition of sudden death due to arrhythmia relies on the time interval between onset of symptoms and death. However, not all sudden deaths are due to arrhythmia. In patients with an ...implantable cardioverter defibrillator (ICD), postmortem device interrogation may help better distinguish the mode of death compared to a time‐based definition alone.
Objective
This study aims to assess the proportion of “sudden” cardiac deaths in patients with an ICD that have confirmed arrhythmia.
Methods
We conducted a literature search for studies using postmortem ICD interrogation and a time‐based classification of the mode of death. A modified QUADAS‐2 checklist was used to assess risk of bias in individual studies. Outcome data were pooled where sufficient data were available.
Results
Our search identified 22 studies undertaken between 1982 and 2015 with 23,600 participants. The pooled results (excluding studies with high risk of bias) suggest that ventricular arrhythmias are present at the time of death in 76% of “sudden” deaths (95% confidence interval CI 67–85; range 42–88).
Conclusion
Postmortem ICD interrogation identifies 24% of “sudden” deaths to be nonarrhythmic. Postmortem device interrogation should be considered in all cases of unexplained sudden cardiac death.
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