Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.

PurposeSudden cardiac arrest is a common emergency condition found in the emergency department of the hospital. The survival rate of out-of-hospital cardiac arrest patients is 2.0%–10.0% and 7.4%–27.0% percent for in-hospital cardiac arrest patients. The factors for survival outcome are divided into three main groups: patient characteristics, pre-hospital factors, and resuscitated information. The objective of this study was to evaluate the related factors, outcome, and survival rate in patients with cardiac arrest who received cardiopulmonary resuscitation (CPR) at Ramathibodi Emergency Medicine Department. There are limited data for this issue in Thailand and other Asian countries.MethodsThis retrospective study included all patients who were older than 15 years with sudden cardiac arrest and who were resuscitated in the emergency room between January 2005 and December 2010. Descriptive analytic statistics and logistic regressions were used to analyze factors that related to the sustained return of spontaneous circulation (ROSC) and survival at discharge.ResultsThere were 181 patients enrolled. The overall sustained ROSC rate was 34.8% and the survival rate at discharge was 11.1%. There were 145 out-of-hospital cardiac arrest patients, in whom the survival rate was 52.4% and the survival to discharge rate was 7.6%. For inhospital cardiac arrest, there were 36 patients with a survival rate of 86.1% and the survival to discharge rate was 25.0%. Statistically significant factors related to sustained ROSC were good and moderate cerebral performance, in-hospital cardiac arrest, beginning of CPR in less than 30 minutes, and cardiopulmonary cause of arrest. The factors influencing survival to discharge were cardiopulmonary causes of cardiac arrest.ConclusionFactors associated with sustained ROSC were functional status before cardiac arrest, location of cardiac arrest, duration of CPR, and cause of cardiac arrest. Survival rate was related to the cause of cardiac arrest.

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BackgroundChest compression quality is a determinant of survival from sudden cardiac arrest. The CPR RsQ Assist Device (CPR RAD) is a new cardiopulmonary resuscitation device for chest compression. It is operated manually but it does not pull up on the chest on the up stroke. The aim of this study was to compare the CPR RAD with standard manual compression in terms of chest compression quality in a manikin model.MethodsParticipants were randomly assigned to either the device or manual chest compression group. Each participant performed a maximum of 4 minutes of hands-only compression with or without the device. During chest compression, the following quality parameters from the manikin were recorded: compression rate, compression depth, and correctness of hand position.ResultsDuration of chest compression was significantly higher in device users compared with manual compression (223.93±36.53 vs 179.67±50.81 seconds; P<0.001). The mean compression depth did not differ in a statistically significant way between manual compression and device at 2 minutes (56.42±6.42 vs 54.25±5.32; P=0.052). During the first and second minutes, compression rate was higher in cases of standard compression (133.21±15.95 vs 108±9.45; P<0.001 and 127.41±27.77 vs 108.5±9.93; P<0.001). There was no statistically significant difference in the percentage of participants who employed compression that was too shallow or exhibited incorrect hand position.ConclusionThe CPR RAD is more effective in chest compression compared with manual chest compression, as using the device led to better results in terms of fatigue reduction and correct compression rate than standard manual compression.

Background: Sepsis screening in the emergency department (ED) is challenging. The quick Sequential Organ Failure Assessment (qSOFA) score had poor accuracy for predicting mortality in both the intensive care unit and ED. High lactate levels were associated with an increased mortality. However, a previous study using lactate levels in combination with the qSOFA score did not observe a meaningful improvement in predictive accuracy. This study assessed the prognostic accuracy of venous lactate levels plus the qSOFA (VqSOFA) score for predicting 28-day mortality. Methods: Patients who visited the Ramathibodi ED with suspected sepsis were enrolled. The VqSOFA, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores were calculated using the initial vital signs and laboratory values. Prognostic accuracy was measured using the area under the receiver operating characteristic (AUROC) curve of the VqSOFA score and Sepsis-3 criteria for predicting 28-day mortality. Results: In total, 1,139 patients were enrolled, 118 of whom died within 28 days of admission. The AUROCs of the VqSOFA, qSOFA, and SOFA scores were 0.851 (95% CI 0.813-0.889), 0.813 (95% CI 0.772-0.854), and 0.728 (95% CI 0.671-0.784), respectively. Using VqSOFA score 3 as the cutoff, the sensitivity, specificity, and positive likelihood ratio were 74.6%, 82.5%, and 4.25%, respectively. VqSOFA 3 was linked to a low probability of 28-day survival and higher odds of vasopressor and ventilator use within 24 h. Conclusions: VqSOFA was more predictive of 28-day mortality and vasopressor and mechanical ventilator use than the qSOFA and SOFA scores. KEYWORDS-Lactate, mortality, qSOFA, sepsis, SOFA ABBREVIATIONS-AUROC-area under the receiver operating characteristic; CI-confidence internval; ED-emergency department; ICU-intensive care unit; IQR-interquartile range; qSOFA-quick Sequential Organ Failure Assessment; SD-standard deviation; SOFA-sequential organ failure assessment; VqSOFA-initial venous lactate level plus the qSOFA score Patient selection and the inclusion and exclusion criteriaThe patients 18 years and older who visited the Ramathibodi ED with suspected sepsis and underwent the Ramathibodi sepsis protocol from February 20, 2019, to February 19, 2020, identified by using software (RAMA-EMR) database, were enrolled. The exclusion criteria were as follows: infection by microbes other than bacteria such as viruses, submission of a donot-attempt resuscitation order, transfer to other hospitals, receipt of medical treatment at another hospital before arrival to our ED, and missing data.

Background Visits to the emergency department (ED) are inflection points in patients’ illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. Methods This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL. Discussion In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients’ self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. Trial registration ClinicalTrials.gov identifier: NCT05209880

Background. Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population. Methods. This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis. Result. During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times. Conclusion. Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Introduction: The Surviving Sepsis Campaign published the Hour-1 Sepsis Bundle in 2018. The first-hour management of patients with sepsis in the emergency department (ED) is important, as suggested in the Hour-1 Sepsis Bundle.The objectives of the present study were to evaluate 28-day mortality and delayed septic shock with use of a complete and incomplete Hour-1 Sepsis Bundle in the ED. Methods: This prospective cohort study included adult patients with sepsis from March to July 2019. We followed the sepsis protocol used in the ED of a tertiary care hospital. Results: We enrolled 593 patients, with 55.9% in the complete Hour-1 Sepsis Bundle group. The 28-day mortality was 3.9% overall and no significant difference between the complete and incomplete Hour-1 Sepsis Bundle groups (3.6% vs. 4.2%, P ¼ 0.707). Complete Hour-1 Sepsis Bundle treatment was not associated with 28-day mortality (adjusted OR ¼ 2.04, 95% confidence interval [CI] ¼ 0.72-5.74, P ¼ 0.176) or delayed septic shock (adjusted OR ¼ 0.74, 95% CI ¼ 0.30-1.78, P ¼ 0.499). Completion of each bundle did not affect outcomes of 28-day mortality and delayed septic shock. Conclusions: The complete Hour-1 Sepsis Bundle treatment in the ED was not significantly associated with 28-day mortality and delayed septic shock. Trial registration: The trial was registered in the Thai Clinical Trial Registry, TCTR 20200526013.