Unsuspected Pulmonary Embolism in Observation Unit Patients

Objective: Many emergency department (ED) patients with cardiopulmonary symptoms such as chest pain or dyspnea are placed in observation units but do not undergo specific diagnostic testing for pulmonary embolism (PE). The role of observation units in the diagnosis of PE has not been studied. We hypothesized that there was a small but significant rate of unsuspected PE in our observation unit population.Methods: We performed a retrospective chart review at an urban academic hospital of all ED patients with an International Classification of Diseases, Ninth Revision diagnosis of PE between January 2005 and July 2006. The number of such patients assigned to observation at any point in their stay was recorded, in addition to events leading to diagnosis and subsequent in-hospital outcomes.Results: Thirteen of the 190 ED patients diagnosed with PE were placed in the observation unit. Six of these either had a known recent diagnosis of PE or had testing for PE initiated prior to placement in the observation unit. Two of the remaining seven patients with undiagnosed PE were placed in observation for undifferentiated chest pain, accounting for 0.09% of the 2190 patients under the chest pain protocol. Twelve of 13 PE patients (92%) were admitted with an average stay of 4.3 days. Of the 13 patients, five were ultimately determined after admission to not have PE, leaving a rate of confirmed PE in the observation unit population of 0.12% (8/6182), with five of eight being classified as unsuspected prior to assignment to observation (0.08% rate).Conclusion: We identified a small number of patients assigned to observation with unsuspected PE. The high rate of hospital admission and prolonged hospital stay suggests that patients with PE are inappropriate for observation status. Given the low incidence of unsuspected PE, there may be a need for a specific approach to screening for PE in observation unit patients.[WestJEM. 2009;10:130-134.

The effect of smoking status on burn inhalation injury mortality

Introduction Three factors that effect burn mortality are age, total body surface of burn (TBSA), and inhalation injury. Of the three, inhalation injury is the strongest predictor of mortality thus its inclusion in the revised Baux score (age + TBSA + 17* (inhalation injury, 1 = yes, 0 = no)). However, the weighted contribution of specific comorbidities such as smoker status on mortality has traditionally not been accounted for nor studied in this subset of burn patients. We therefore sought to examine the impact of current tobacco and/or marijuana smoking in patients with inhalation injury. Methods A retrospective analysis of patients admitted to a regional burn center from 2002 to 2012. Independent variables analyzed included basic demographics, burn mechanism, presence of inhalation injury, TBSA, pre-existing comorbidities, and smoker status. Bivariate analysis was performed and logistic regression modeling using significant variables was utilized to estimate odds of mortality. Results There were a total of 7640 patients over the study period. 7% (n = 580) of the burn cohort with inhalation injury were included in this study. In-hospital burn mortality for inhalation injury patients was 23%. Current smokers (20%) included cigarette smokers and marijuana users, 19% and 3%, respectively. Preexisting respiratory disease (17%) was present in 36% of smokers compared to 13% of non-smokers (p < 0.001). Smokers had significantly lower mortality rate (9%) compared to non-smokers (26%, p < 0.01). The logistic regression model for mortality outcomes identified statistically four significant variables: age, TBSA, ethnicity, and smoker status (OR = 0.41, 95% CI = 0.18–0.93). Presence of comorbidities, including preexisting respiratory disease, was not significant. Conclusion In the sub group of burn patients with inhalation injury, the odds of mortality significantly decreased in pre-existing smokers after adjusting for significant covariates. We postulate that an immune tolerance mechanism that modulates and diminishes the pro-inflammatory response confers a survival advantage in smokers after exposure to acute smoke inhalation injury. Future prospective studies in human and/or animal models are needed to confirm these findings

Mortality after peritonitis in sub-saharan Africa: An issue of access to care

There is a lack of access to emergency surgical care in developing countries despite a burden of surgical disease. Health care systems are overwhelmed by the high volume of patients who need acute care and by insufficient capacity because of a lack of appropriate prehospital care, surgery-capable clinicians, and basic health care delivery infrastructures. Compared with high-income countries where mortality from peritonitis is less than 5%, mortality in this resource-poor setting is nearly 20%. These patients are particularly susceptible because of a lack of the prerequisite surgical infrastructure, which includes prompt triage and diagnosis, early transfer to a higher level of care, timely surgical intervention, and critical care services. This study identifies outcomes of patients with peritonitis and factors that contribute to mortality

Incidence of self-inflicted burn injury in patients with Major Psychiatric Illness

Introduction: Psychiatric disorders are mental illnesses that impair judgment, thought process and mood that can result in physical and emotional disability. According to DSM-IV, mental disorders increases risk of traumatic injury, particularly burn [1] (American Psychiatric Association, 2013). However, there are few studies that look at patients with pre-existing major psychiatric disorders and burn outcomes. We aim to assess the incidence and intentionality of burn injury in patients with pre-existing psychiatric disorders. Methods: This is a retrospective study of patients admitted to the UNC Jaycee Burn Center from 2002 to 2015 and entered in the burn registry. Variables analyzed include basic demographics, insurance status, total body surface area (TBSA) of burn, Charlson comorbidity index (CCI), burn etiology, presence of inhalation injury, burn circumstance, intensive care unit (ICU) and hospital length of stay (LOS) and mortality. Chi-square, Analysis of Variance (ANOVA), Kruskal–Wallis test and Multivariate logistic regression was used to analyze the data. Results: 11,650 adult and pediatric patients were entered in the burn registry from 2002 to 2015 and 494 (4.2%) adult and pediatric patients had preexisting major psychiatric illness (MPI). Within the large cohort of admitted burn patients, 90 (0.8%) patients presented with self-inflicted burn injuries. 41% of patients with SIB (n = 37/90) had MPI. The incidence of self-inflicted burn injury (SIB) within the MPI (n = 494) cohort was 7.5% (n = 37). Mean age of patients with and without self-inflicted burn injury was 35.3 (±11.6) vs. 41.8 (±17.3), respectively. Mean TBSA was significantly higher in patient with SIB at 18.6 (±16.5) vs. 8.5(±12.2) p < 0.001. Non-white race had significantly higher rate of SIB compared to white cohort. There was no significant difference in mortality rates between SIB and Non-SIB (5.4% vs. 3.7%, p = 0.609), respectively. Median Hospital LOS was significantly increased in patients with SIB compared to NSIB 31 (IQR = 55) vs. 9 (IQR = 20) days, p = 0.004. Multivariate logistic regression for predictors of self-inflicted burn injury showed that minorities were more likely to incur self-inflicted burn injury among patients with major psychiatric illnesses. Conclusion: The incidence of self-induced burn injury in patients with MPI is low and of all the self-inflicted burn patients, 60% did not have a major psychiatric illness identified. Our findings emphasize the importance of identifying patients with MPI with or without self-induced injury that may benefit from more extensive psychiatric screening after burn and counseling, particularly minority patients as they may benefit from additional mental health counseling following severe burn

Racial and ethnic disparities in discharge to rehabilitation following burn injury

Racial and ethnic disparities in access to inpatient rehabilitation have been previously described for various injury groups; however, no studies have evaluated whether such disparities exist among burn patients. Their aim was to determine if racial disparities in discharge destination (inpatient rehabilitation, skilled nursing facility, home with home health, or home) following burn injury existed in this single-institution study. A retrospective analysis of all adult burn patients admitted to UNC Jaycee Burn Center from 2002 to 2012 was conducted. Patient characteristics included age, gender, burn mechanism, insurance status, percentage total body surface area (%TBSA) burned, presence of inhalation injury, and hospital length of stay. Patients were categorized into one of three mutually exclusive racial or ethnic groups: White, Hispanic, or Black. Propensity score weighting followed by ordered logistic regression was performed in the analytical sample and in a subgroup analysis of patients with severe burns (TBSA > 20%). For analysis, 4198 patients were included: 2661 White, 340 Hispanic, and 1197 Black. Propensity weighting resulted in covariate balance among racial groups. Black patients (OR: 1.58, 95% CI: 1.23-2.03; P <.001) were more likely than Whites to be discharged to a higher level of rehabilitation, whereas Hispanics were less likely (OR: 0.78, 95% CI: 0.38-1.58; P =.448). In their subgroup analysis, Black (OR: 1.88, 95% CI: 1.07-3.28; P =.026) and Hispanic (OR: 1.53, 95% CI: 0.31-7.51; P =.603) patients were more likely to discharge to a higher level of rehabilitation than White patients. Racial and ethnic disparities in discharge destination to a higher level of rehabilitative services among burn-injured patients exist particularly for Hispanic patients but not for Black or White burn patient groups. Further studies are needed to elucidate the potential sources of these disparities specifically for Hispanic patients

The Effect of Pre-existing Seizure Disorders on Mortality and Hospital Length of Stay Following Burn Injury

Patients with a seizure disorder have a higher incidence of burn injury; however, there are limited studies that examine the association between pre-existing seizure disorders (PSD) and burn outcomes. This is a retrospective study of admitted burn patients. Variables analyzed include patient demographics, clinical characteristics, associated PSD, hospital length of stay (LOS), and mortality. Multivariate logistic regression was performed to analyze the impact of PSD on burn mortality and LOS. Seven thousand six hundred and forty patients met the inclusion criteria and 1.31% (n = 100) patients had a PSD. There was no difference in mortality rate between patients with or without PSD (odds ratio [OR] = 2.28, 95% confidence interval [CI] = 0.87 to 5.93). Multivariate logistic regression showed that patients with PSD had significantly increased odds of longer hospital LOS (OR = 2.85, 95% CI = 1.73 to 4.67). Seizure disorder management is mandatory in reducing burn injury and decreasing the costs associated with increased hospital LOS

The epidemiologic characteristics and outcomes following intentional burn injury at a regional burn center

Introduction: Intentional burn injury outcomes are usually more severe, have a high mortality and are seen more often in low and middle-income countries. This study will examine the epidemiological characteristics of intentional burn injury patients and mortality outcomes at a regional Burn Center. Methods: This is a retrospective study of 11,977 patients admitted to a regional Burn center from 2002 to 2015.Variables analyzed were basic demographics (sex, age, and race), total body surface area of burn (%TBSA), presence of inhalation injury, Charlson comorbidity index, intent of injury, mortality, and hospital and ICU length of stay (LOS). Chi-square tests, bivariate analysis and logistic regression models were utilized to determine the effect of burn intent on outcomes. Results: Eleven thousand eight hundred and twenty-three (n = 11,823) adult and pediatric patients from 2002 to 2015 were included in the study. Three hundred and forty-eight (n = 348, 2.9%) patients had intentional burn injuries (IBI). Patients with IBI were younger, 26.5 ± 20 years compared to the non-intentional burn injury (NIBI) group (32 ± 22 years, p < 0.001). Mean %TBSA was significantly higher in the IBI vs. NIBI group at 14.6 ± 20 vs. 6.4 ± 10%, p < 0.001, respectively. Overall, Non-whites (n = 230, 66%) were more likely to have IBI, p < 0.001. Inhalation injury and mortality were statistically significant in the IBI group compared to the NIBI group, (n = 54,16%) vs. (n = 30, 9%) and (n = 649,6%) vs. (n = 329,2.9%), p < 0.001, respectively. Multivariate logistic regression did not show any significant increase in odds of mortality based on burn intent. In subgroup analysis of self-inflicted (SIB) vs. assault burns, SIB patients were significantly older, 38 years (±14.7) vs. 22.4 years (±20.5), p < 0.001 and had a higher %TBSA, 26.5 (±29.6) vs. 10.3 (±13.6), p < 0.001. Seventy three percent (n = 187, 73%) of assault burn patients were Nonwhite and Whites were more likely to incur self-inflicted burns, (n = 53% p < 0.001). Conclusion: We show that patients with intentional burn injuries have an associated increased %TBSA and inhalation injury without increased adjusted odds for mortality. Intentional burns increase health care expenditures. Violence prevention initiatives and access to mental health providers may be beneficial in reducing intentional burn injury burden

Predictors of withdrawal of life support after burn injury

Introduction: Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. Methods: We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17 years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. Results: 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18–3.48; p = 0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08–1.52; p = 0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06–1.12; p < 0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07–1.51; p < 0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05–5.78; p = 0.038) was also found in patients with inhalation injury. Conclusion: The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P =.009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P =.012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P =.010), electric (OR: 13.54; 95% CI: 6.23-29.45; P <.001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P <.001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study