Editor’s note: Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals, and are not peer reviewed or edited by Hong Kong Journal of Emergency Medicine.
Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST
Thomas C Sauter, Simon Hoess, Beat Lehmann, Aristomenis K Exadaktylos and Dominik G Haider
Published Online First: 12 May 2017. doi: 10.1136/emermed-2016-205980
Background: Extended focused assessment with sonography for trauma (eFAST) has been shown to have moderate sensitivity for detection of pneumothorax in trauma. Little is known about the location or size of missed pneumothoraces or clinical predictors of pneumothoraces in patients with false-negative eFAST.
Methods: This retrospective cross-sectional study includes all patients with multiple blunt trauma diagnosed with pneumothorax who underwent both eFAST and CT performed in the ED of a level 1 trauma centre in Switzerland between 1 June 2012 and 30 September 2014. Sensitivity of eFAST for pneumothorax was determined using CT as the gold standard. Demographic and clinical characteristics of those who had a pneumothorax detected by eFAST and those who did not were compared using the Mann-Whitney U or Pearson’s χ2 tests. Univariate binary logistic regression models were used to identify predictors for pneumothoraces in patients with negative eFAST examination.
Results: The study included 109 patients. Overall sensitivity for pneumothorax on eFAST was 0.59 and 0.81 for pneumothoraces requiring treatment. Compared with those detected by eFAST, missed pneumothoraces were less likely to be ventral (30 (47.6%) vs 4 (9.3%), p <0.001) and more likely to be apical and basal (7 (11.1%) vs 15 (34.9%), p=0.003; 11 (17.5%) vs 18 (41.9%), p=0.008, respectively). The missed pneumothoraces were smaller than the detected pneumothoraces (left side: 30.7 ± 17.4 vs 12.1 ± 13.9 mm; right side: 30.2 ± 10.1 vs 6.9 ± 10.2 mm, both p <0.001). No clinical variables were identified which predicted pneumothoraces in falsely negative eFAST. Among those pneumothoraces missed by eFAST, 30% required tube thoracostomy compared with 88.9% of those detected with eFAST.
Conclusion: In our study, pneumothoraces missed by eFAST were smaller and in atypical locations compared with those detected by eFAST and needed thoracic drainage less often.
Annals of Emergency Medicine
Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality
Daniel W Spaite, Chengcheng Hu, Bentley J Bobrow, Vatsal Chikani, Bruce Barnhart, Joshua B Gaither, Kurt R Denninghoff, P David Adelson, Samuel M Keim, Chad Viscusi, Terry Mullins, Amber D Rice and Duane Sherrill
Study Objective: Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury (TBI). The association of TBI mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury.
Methods: We evaluated adults and older children with moderate or severe TBI in the preimplementation cohort of Arizona’s statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders.
Results: There were 7,521 TBI cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mmHg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log 2 (the logarithm in base 2) of hypotension dose was associated with TBI mortality (adjusted odds ratio 1.19 [95%CI 1.14 to 1.25] per 2-fold increase of dose).
Conclusion: In this study, the depth and duration of out-of-hospital hypotension were associated with increased TBI mortality. Assessments linking out-of-hospital blood pressure with TBI outcomes should consider both depth and duration of hypotension.
How to cite this article:
Spaite DW, Hu C, Bobrow BJ, et al. Association of out-of-hospital hypotension depth and duration with traumatic brain injury mortality. Ann Emerg Med 2017. http://dx.doi.org/10.1016/j.annemergmed.2017.03.027
African journal of emergency medicine
The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria and the Rwanda Emergency Care Association.
A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town
Matthews R, McCaul M, Smith W. A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town. Afr J Emerg Med 2017; 7(1): 24–29
Introduction: Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.
Methods: A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.
Results: A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66–74) cases, nitrates in 197 (37%, 95% CI 33–41) and ketamine in 9 (1.7%, 95% CI 1–3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70–79) cases, with the median dose being 4 mg (IQR 3–6). Single doses were administered to 268 (72.2%, 95% CI 67–77) morphine administrations, five (56%, 95% CI 21–86) ketamine administrations and 161 (82%, 95% CI 76–87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2–4).
Discussion: Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.
Hospital emergency room diagnosis of acute appendicitis in patients aged 2 to 20 years: the INFURG-SEMES score from the emergency infections study of the Spanish Society of Emergency Medicine
Kinda Altali, Pedro Ruiz-Artacho, Victoria Trenchs, Mikel Martínez Ortiz de Zárate, Carmen Navarro, Cristina Fernández, Andrés Bodas-Pinedo, Juan González-Del Castillo and Francisco Javier Martín-Sánchez
http://emergencias.portalsemes.org/descargar/escala-infurgsemes-para-el-diagnstico-de-apendicitis-aguda-en-los-pacientes-de-2-a-20-aos-atendidos-en-los-servicios-de-urgencias-hospitalarios/
Cited: Altali K, Ruiz-Artacho P, Trenchs Sainz De La Maza V, Martínez Ortiz de Zárate M, Navarro C, Fernández C, et al. Hospital emergency room diagnosis of acute appendicitis in patients aged 2 to 20 years: the INFURG-SEMES score from the emergency infections study of the Spanish Society of Emergency Medicine. Emergencias 2017; 29: 231–236.
Objectives: To develop the INFURG-SEMES scale (based on the emergency infections study of the Spanish Society of Emergency Medicine) using clinical and laboratory data to diagnose acute appendicitis (AA) in patients aged 2 to 20 years who were evaluated in hospital emergency departments and to compare its diagnostic yield to that of the Alvarado score.
Methods: Prospective observational cohort study enrolling consecutive patients between the ages of 2 and 20 years who came to 4 hospital emergency departments with abdominal pain suggestive of AA and of less than 72 hours’ duration. We collected demographic, clinical, analytic (white blood cell count, differential counts, and C–reactive protein [CRP] levels), and radiographic data (ultrasound and/or computed tomography scans). We also recorded surgical data if pertinent. The main outcome was a diagnosis of AA within 14 days of the index visit.
Results: We included 331 patients with a mean (SD) age of 11.8 (3.8) years; 175 (52.9%) were male. The final diagnosis was AA in 116 cases (35.0%). The INFURG-SEMES scale included the following predictors: male sex, right quadrant pain (right iliac fossa) on examination, pain on percussion, pain on walking, and elevated neutrophil count and CRP level. The areas under the receiver operating characteristic curves for the INFURG-SEMES scale and the Alvarado score, respectively, were 0.84 (95% CI, 0.79–0.88) and 0.77 (95% CI, 0.72–0.82). The difference was statistically significant (P=.002).
Conclusions: The INFURG-SEMES scale may prove useful for diagnosing AA in patients aged between 2 and 20 years evaluated for abdominal pain in hospital emergency departments. The INFURG-SEMES score showed greater discrimination than the Alvarado score.
