Current Issue : January - March Volume : 2017 Issue Number : 1 Articles : 8 Articles
We present two separate cases of youngmale patients with congenital kidney anomalies (horseshoe and crossed fused renal ectopia)\nidentified following blunt abdominal trauma.Despite being rare, ectopic and fusion anomalies of the kidneys are occasionally noted\nin a trauma patient during imaging or upon exploration of the abdomen. Incidental renal findings may influence the management\nof traumatic injuries to preserve and protect the patient�s renal function. Renal anomalies may be asymptomatic or present with\nhematuria, flank or abdominal pain, hypotension, or shock, even following minor blunt trauma or low velocity impact. It is\nimportant for the trauma clinician to recognize that this group of congenital anomalies may contribute to unusual symptoms such\nas gross hematuria after minor trauma, are readily identifiable during CT imaging, and may affect operative management. These\npatients should be informed of their anatomical findings and encouraged to return for long-term follow-up....
Background: Traumatic brain injury (TBI) is a heterogeneous syndrome with a broad range of outcome. We\ndeveloped a simple model for long-term outcome prognostication after severe TBI.\nMethods: Secondary data analysis of a large multicenter randomized trial. Patients were grouped according to 6-month\nextended Glasgow outcome scale (eGOS): poor-outcome (eGOS ââ?°Â¤ 4; severe disability or death) and acceptable outcome\n(eGOS > 4; no or moderate disability). A prediction decision tree was built using binary recursive partitioning to predict\npoor or acceptable 6-month outcome. Comparison to two previously published and validated models was made.\nResults: The decision tree included the predictors of head Abbreviated Injury Scale (AIS) severity, the Marshall computed\ntomography score, and pupillary reactivity. All patients with a head AIS severity of 5 were predicted to have a poor\noutcome. In patients with head AIS severity < 5, the model predicted an acceptable outcome for (1) those with Marshall\nscore of 1, and (2) those with Marshall score above 1 but with reactive pupils at admission. The decision tree had a\nsensitivity of 72.3 % (95 % CI: 66.4ââ?¬â??77.6 %) and specificity of 62.5 % (95 % CI: 54.9ââ?¬â??69.6 %). The proportion correctly\nclassified for the comparison models was similar to our model. Our model was more apt at correctly classifying those\nwith poor outcome but more likely to misclassify those with acceptable outcome than the comparison models.\nConclusion: Predicting long-term outcome early after TBI remains challenging and inexact. This model could be useful\nfor research and quality improvement studies to provide an early assessment of injury severity, but is not sufficiently\naccurate to guide decision-making in the clinical setting....
Background: Improved ability to rapidly rule-out Acute Myocardial Infarction (AMI) in patients presenting with\nchest pain will promote decongestion of the Emergency Department (ED) and reduce unnecessary hospital\nadmissions. We assessed a new commercial Heart Fatty Acid Binding Protein (H-FABP) assay for additional\ndiagnostic value when combined with cardiac troponin (using a high sensitivity assay).\nMethods: H-FABP and high-sensitivity troponins I (hs-cTnI) and T (hs-cTnT) were measured in samples taken\non-presentation from patients, attending the ED, with symptoms triggering investigation for possible acute coronary\nsyndrome. The optimal combination of H-FABP with each hs-cTn was defined as that which maximized the proportion\nof patients with a negative test (low-risk) whilst maintaining at least 99 % sensitivity for AMI. A negative test comprised\nboth H-FABP and hs-cTn below the chosen threshold in the absence of ischemic changes on the ECG.\nResults: One thousand seventy-nine patients were recruited including 248 with AMI. H-FABP < 4.3 ng/mL plus hs-cTnI\n< 10.0 ng/L together with a negative ECG maintained >99 % sensitivity for AMI whilst classifying 40.9 % of patients as\nlow-risk. The combination of H-FABP < 3.9 ng/mL and hs-cTnT < 7.6 ng/L with a negative ECG maintained the same\nsensitivity whilst classifying 32.1 % of patients as low risk.\nConclusions: In patients requiring rule-out of AMI, the addition of H-FABP to hs-cTn at presentation (in the absence of\nnew ischaemic ECG findings) may accelerate clinical diagnostic decision making by identifying up to 40 % of such\npatients as low-risk for AMI on the basis of blood tests performed on presentation. If implemented this has the\npotential to significantly accelerate triaging of patients for early discharge from the ED....
Background: Ketamine has been well studied for its efficacy as an analgesic agent. However, intranasal (IN)\nadministration of ketamine has only recently been studied in the emergency setting. The objective of this study was to\nelucidate the efficacy and adverse effects of a sub-dissociative dose of IN Ketamine compared to IV and IM morphine.\nMethods: A single-center, randomized, prospective, parallel clinical trial of efficacy and safety of IN ketamine compared\nto IV and IM morphine for analgesia in the emergency department (ED). A convenience sample of 90 patients aged\n18ââ?¬â??70 experiencing moderate-severe acute traumatic pain (ââ?°Â¥80 mm on 100 mm Visual Analog Scale [VAS]) were\nrandomized to receive either 1.0 mg/kg IN ketamine, 0.1 mg/kg IV MO or 0.15 mg/kg IM MO. Pain relief and adverse\neffects were recorded for 1 h post-administration. The primary outcome was efficacy of IN ketamine compared to IV\nand IM MO, measured by ââ?¬Å?time-to-onsetââ?¬Â (defined as a ââ?°Â¥15 mm pain decrease on VAS), as well as time to and degree\nof maximal pain reduction.\nResults: The 3 study groups showed a highly significant, similar maximal pain reduction of 56 Ã?± 26 mm for IN\nKetamine, and 59 Ã?± 22 and 48 Ã?± 30 for IV MO and IM MO, respectively. IN Ketamine provided clinically-comparable\nresults to those of IV MO with regards to time to onset (14.3 Ã?± 11.2 v. 8.9 Ã?± 5.6 min, respectively) as well as in time to\nmaximal pain reduction (40.4 Ã?± 16.3) versus (33.4 Ã?± 18), respectively.\nConclusions: IN ketamine shows efficacy and safety comparable to IV and IM MO. Given the benefits of this mode of\nanalgesia in emergencies, it should be further studied for potential clinical applications...
Background: Dizziness is a common chief complaint of patients presenting to the Emergency Department (ED).\nPhysicians must quickly and accurately identify patients whose etiology is most likely ischemia. Additional tools are\navailable, but often require further training (vestibular testing) or are costly and not always readily available\n(magnetic resonance imaging (MRI)). This study evaluates the ability of a routine history and simple physical\nexamination to correctly identify dizzy patients with posterior circulation ischemia, and the added utility of CT\nangiography (CTA).\nMethods: We performed a retrospective analysis of all individuals presenting to the ED with a reported chief\ncomplaint of dizziness. Neurology was consulted and CTA ordered at the discretion of the ED provider. Demographic,\nmedical, and radiographic variables were evaluated along with final diagnosis. Multivariable logistic regression and ROC\nanalysis were used to determine factors associated with ischemia, the sensitivity of vascular risk factors and focal exam\nfindings in predicting ischemia, and the additional benefit, if any, of CTA.\nResults: One thousand two-hundred sixteen individuals meeting inclusion criteria presented to the ED over a 2 year\nperiod and were included in analysis. One hundred (8.2 %) were diagnosed with posterior circulation ischemia. For the\nentire cohort, age (OR 1.4 per 10 years, p < 0.0001), systolic blood pressure (OR 1.3 per 10 mmHg, p < 0.0001), and focal\nexam findings (OR 28.69, p < 0.0001) were most significantly associated with ischemia in multivariable modeling. When\nage, race, sex, presence of vascular risk factors, and focal neurologic findings were entered into ROC analysis, the AUC\nfor correctly identifying posterior circulation ischemia was 0.90. In the subset of patients who underwent CTA (n = 87),\nthe AUC did not improve (0.78 with and without CTA in ROC analysis, p = 0.52).\nConclusions: A vascular risk assessment and neurological examination are adequate for risk stratification of ischemia in\nthe dizzy patient and should remain the standard evaluation...
Mandibular fracture is a common occurrence in emergencymedicine and belongs to the most frequent facial fractures.Historically\nroad traffic injuries (RTIs) have played a prominent role as a cause for mandibular fractures. We extracted data from all patients\nbetween August 2012 and February 2015 with ââ?¬Å?lower jaw fractureââ?¬Â or ââ?¬Å?mandibular fractureââ?¬Â from the routine database from the\nemergency department. We conducted a descriptive analysis at a Swiss level one trauma centre. 144 patients were admitted with\nsuspected mandibular fractures. The majority underwent CT diagnostic (83%). In 7% suspected mandibular fracture was not\nconfirmed. More than half of all patients suffered two or more fractures. The fractures were median or paramedian in 77/144\npatients (53%) and in other parts (corpus, mandibular angle, ramusmandibularis, collum, and temporomandibular joint) in 100/144\n(69%). Male to female ratio was 3 : 1 up to 59 years of age; 69% were younger than 40 years. 72% of all patients presented during\ndaytime, 69% had to be hospitalized, and 31% could be discharged from the ED after treatment. Most fractures were due to fall\n(44%), followed by interpersonal violence (25%) and sport activities (12%). Falls were a dominant cause of fracture in all age groups\nwhile violence and sport activities were common only in younger patients. Comparisons to other studies were difficult due to lack\nof standardization of causes contributing to the injuries. In the observed time period and setting RTIs have played a minor role\ncompared to falls, interpersonal violence, and sports. In the future, standardized documentation as well as categorization of causes\nfor analytic purposes is urgently needed to facilitate international comparison of studies....
Background: Psychological distress in medical patients admitted to the emergency department (ED) is not well\nstudied. Our aim was to investigate the extent of psychological distress in a broad and unselected medical patient\nsample 30 days after ED admission and its association with socio-demographic and clinical variables.\nMethod: We used data from a prospective observational cohort study including 1575 consecutive adult medical\npatients presenting to the ED with acute somatic conditions. Outcome variables were patientââ?¬â?¢s psychological\ndistress measured by the 4-item Patient Health Questionnaire (PHQââ?¬â??4) and self-rated health assessed 30 days after\nED admission using telephone interviews. Risk factors included socio-demographic variables (e.g. gender, marital\nstatus), clinical presentation (e.g. illness severity, main initial diagnosis) and course of illness (e.g. rehospitalisation,\nlength of hospital stay).\nResults: A total of 38 % of patients had evidence for psychological distress 30 days after ED admission. Multivariate\nanalysis found female gender (adjusted odds ratio [aOR] 1.35, 95 % confidence interval [CI] 1.02 to 1.78), comorbid\npsychiatric disorder (aOR 1.63, 95 % CI 1.08 to 2.62), discharge to a post-acute care institution (aOR 1.47, 95 % CI 1.\n03 to 2.09), unplanned rehospitalisation (aOR 2.38, 95 % CI 1.47 to 3.86), and unplanned visit at general practitioner\n(aOR 4.75, 95 % CI 2.57 to 8.80) to be associated with distress at day 30 following ED admission.\nConclusions: One month after ED admission a significant number of patients still show a moderate amount of\npsychophysical distress. Strongest related variables were course of illness, in particular unplanned general practitioner\nvisits. Future interventional studies should assess possibilities to reduce distress in patients at increased risk.\nTrial registration: NCT01768494, January 9, 2013 (registration date), February 25, 2013 (enrolment of first participant...
Background: Between 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers\n(under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians\nignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression\nbased on representativeness (how typical does a patient appear of one with severe injuries). We created a video\ngame (Night Shift) to recalibrate physician�s representativeness heuristic in trauma triage.\nMethods: We developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral\nscientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who\naccepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual\ncues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive\nemotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study\nwill compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician\nheuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing\nthe under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to\nplay the game or to review an educational program, and will assess performance using a validated virtual\nsimulation. The validated simulation includes both control and cognitive load conditions. We will compare\nrates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect\nof cognitive load on physicians� under-triage rates (secondary outcome). We hypothesize that: a) physicians\nexposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational\nprogram, and b) cognitive load will not degrade triage performance among physicians exposed to Night\nShift as much as it will among those exposed to the educational program.\nDiscussion: Serious games offer a new approach to the problem of poorly-calibrated heuristics in trauma\ntriage. The results of this trial will contribute to the understanding of physician quality improvement and\nthe efficacy of video games as behavioral interventions...
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