This large retrospective database study compared those receiving antibiotics after anterior nasal packing to those that did not. There was no difference in clinically significant infection between the groups leading the authors to conclude prophylactic antibiotics after anterior nasal packing is not required.
Looking at a year’s worth of data from the National Trauma Databank, the authors found incarcerated trauma patients were more likely to be stabbed, male, persons of color and have a higher adjusted mortality rate.
This article reminds us that hip fractures have a one year mortality rate of 12-25% and 50% of hip fracture patients develop complications while in the hospital. “Almost half of individuals hospitalized with hip fractures experience complications, such as delirium, pneumonia, acute kidney injury, urinary tract infection, and deep vein thrombosis”
Because of these complications, multidisciplinary teams should be caring for these patients and great care should be exercised when evaluating these patients.
Aortic dissection remains a difficult diagnosis to make. This article is a nice review. The pathology behind this involves an intimal flap in the aortic wall. Death occurs due to aortic rupture or obstruction of branching artery.
Risk factors: male 2:1 female, Marfan Syndrome, HTN, aortic aneurysm, cocaine and methamphetamine use, pregnancy
Pain is variable however tearing, ripping migrating, maximum at onset, and sharp are all associated with Aortic Dissection. Think about Dissection with atypical CP with ECG changes as well as in stroke like presentations along with chest pain.
Gold standard for diagnosis is CT angiogram. Decision rules with the use of D-Dimer have been proposed however there is still not sufficient evidence to use these. ACEP guidelines currently give use of decision rules a long with DDImer a level C recommendation.
This study looked at exposure to gun violence and found increased use of mental health resources, depression and suicide risk even with a single exposure. Repetitive exposure increased suicide risk as well as mental health service utilization, depression and overall health service utilization. While further work is needed, screening our patients for gun violence exposure could undercover mental health needs.
In the April edition of Annals of EM, there are opposing view points on the optimal antibiotic regiment for necrotizing soft tissue infection. One group proposes linezolid alone will cover all the worrisome pathogens namely group A Strep and Staph. There are less side effects including C. Diff infection with this medication. Another group suggests sticking to vancomycin plus/minus BLactam along with clindamycin. Their arguement centers around clindamycin is useful as an antitoxin more so than its antibacterial property.
Both offer reasonable evidence and neither is compelling enough to say one is superior to the other.
This study looking at the type of facility that cared for rural injured patients reminds us that the majority of trauma care for rural patients occurs in non-trauma centers. This included some of the most severely injured and for many definitive care was received at these centers.
This may lead to lack of inclusion in trauma registries and under valuing the care being delivered by non-trauma centers. Protocols to facilitate transfers, air medical protocols and availability along with tele-health all are important in rural trauma care. Non-trauma designated centers are a critical part of the trauma network for rural residents and their value can not be ignored.
This study looked at pre-trauma mental health diagnosis (from medical records) and post-trauma mental health symptoms as assessed by survey. The majority of patients suffered blunt trauma and mean age was 67. Having pre/traumatic mental health diagnosis and particularly post-traumatic symptoms lead to worse health outcomes and financial conditions. Further work needs to be done to assess how to improve mental health symptoms post-traumatic injury.
Missed appendicitis leading to rupture and peritonitis leads to morbidity, mortality, and malpractice claims. Part of a longer article looking at evaluation and management of appendicitis, these authors provide three scoring systems that can be used to identify appendicitis. Use of these scores can guide imaging and surgical consultation.
Alvarado Score: If a patient scores 1 to 4, the risk of appendicitis drops to 33%. If a patient scores >5, the risk of acute appendicitis is 66% or greater.
This study from Australia reminds us that what patients think they ingested isn’t always what they did ingest. A high percentage of “cocaine” and other stimulants was actually fentanyl or other opiates. The authors do a nice job referencing similar studies in the United States. Any overdose could be a mixed picture due to impure street drugs.
The Jarisch-Herxheimer reaction (JHR) is a non-specific set of symptoms (fever, malaise, worsened rash, hemodynamic instability, leukocytosis) seen after treating syphillis and other spirochete induced infections. In this study 1 in 4 patients treated with 2.4 million units of benzathine penicillin G developed a short lived JHR. Those who developed the reaction were more likely HIV negative, had secondary syphillis and had successful treatment at 6 months.
The American Society of Anesthesia score was an independent predictor of 90-day mortality as
well as low functional status at one year in 720 patients presenting to a single center with
moderate to severe brain injury. When used in conjunction with other prognosticating tools such
as the Trauma and Injury Severity Score, it increased the prognostic value of these scales.
Controlling pain from rib fractures impacts morbidity and mortality. Over the past decade there has been a focus on decreasing opiate use and approaching this painful condition in a multimodal way. “The multimodal approach utilizes a combination of delivery methods including oral, parenteral, and regional single-shot or catheter-based techniques. Oral medications include opioids, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, skeletal muscle relaxants, alpha-2 agonists, mood stabilizers, and neuropathic pain medications. Parenteral medications encompass most of the oral options in addition to ketamine and lidocaine. Regional anesthesia includes epidural analgesia (EA), paravertebral blocks, intercostal blocks, and myofascial plane blocks.”
This study is a single center in Canada looking at medication used for patients admitted over 10 years with rib fractures along with demographics, injury severity and outcomes. The authors concluded:
“Although multimodal pain management strategies have improved over time, a large proportion of patients, even among those with flail chest, still do not receive multimodal pain management. Elderly patients, at highest risk of adverse outcomes, were less likely to receive multimodal pain management strategies and should be the target of performance improvement initiatives.”
Achieving faster homeostasis in trauma patients leads to lower mortality, less coagulopathy, and lower total blood volume transfusion requirements. This study looked at time to achieving homeostasis as defined by transfusion requirements as well as laboratory measurements in critically ill trauma patients who either received whole blood or component therapy transfusion as part of their resuscitation. Those receiving whole blood achieved statistically significant faster homeostasis.
Unless a patient is unstable, renal injuries are managed non-operatively or endovascularly. Here is the
2025 Kidney Injury Grading Scale from AAST.
AAST AIS
Grade Severity Imaging Criteria
I 2 –Subcapsular hematoma <3.5 cm without active bleeding
– Parenchymal contusion without laceration
II 2 – Parenchymal laceration length <2.5 cm
– HRD <3.5 cm without active bleeding
III 3 – Parenchymal laceration length ?2.5 cm
– HRD ?3.5 cm without active bleeding
– Partial kidney infarction
– Vascular injuries without active bleeding
– Laceration extending into urinary collecting system and/or urinary extravasation
IV 4 – Active bleeding from kidney
– Pararenal extension of hematoma
– Complete/near-complete kidney infarction without active bleeding
– MFK without active bleeding
– Complete/near-complete ureteropelvic junction disruption
V 5 – Main renal artery or vein laceration or transection with active bleeding
– Complete/near-complete kidney infarction with active bleeding
– MFK with active bleeding
Having a readily measurable variable to identify frailty on admission for critically injured patients would help prognosticate morbidity, mortality, and discharge destination. Sarcopenia has been used to prognosticate length of stay, discharge destination, and physical function recovery in oncology and general surgery patients. Sarcopenia is defined as “age-related progressive loss of muscle mass and strength. The main symptom of the condition is muscle weakness. Sarcopenia is a type of muscle atrophy primarily caused by the natural aging process. Scientists believe being physically inactive and eating an unhealthy diet can contribute to the disease.” 1. This study looked at admission CT scan psoas muscle sarcopenia in 197 critically injured patients. The authors concluded:
“For trauma critical care patients, sarcopenia on admission CT was associated with dependent discharge destination and therefore is unfavourable. Defining sarcopenia early in a trauma patient’s critical care admission may help to identify those at risk of poor outcomes.” 2
The Pan-Asia Trauma Outcomes Study database was reviewed for differences in in-hospital mortality and functional capacity at discharge between male and female trauma patients. There were 76,000 trauma patients from 12 Asian countries in this study. The authors concluded: “This study indicates no difference in the general trauma outcomes in the Asia Pacific between females and males. Although younger females with less severe injuries had better functional outcomes, this advantage disappeared in severe injuries and those over 50 years.” There were several differences in mechanism of injury and age of presentation. “With females more frequently represented in the ??50 age group (60.13%) compared to males (44.87%) (p?<?0.001). Trauma type also varied between sexes; 95.51% of females experienced blunt trauma compared to 93.65% of males (p?<?0.001). Anatomically, males predominantly sustained injuries to the head, face, thorax, abdomen, and upper extremities, whereas females more frequently suffered injuries to the lower extremities and spine (p?<?0.001).” This is similar toEuropean and North American data
Large retrospective propensity matching study looking at mortality in trauma patients based on ALS vs. BLS transport crew found lower mortality in those attended by ALS crews. The matching was “based on patient age, sex, year, ICD-10-CM based injury severity score, mechanism of injury, AIS based body region of injury, EMS characteristics including time with patient and prehospital interventions performed, prehospital vital signs, and trauma center designation.”
This is different than other studies which showed limited difference. other studies have shown improved survival with police “scooping and running” with penetrating trauma patients.
Rib and pelvic fractures are common findings in geriatric trauma patients, even in low impact trauma such as falls from standing. Pain management is vital for improving morbidity and mortality. The IFEM White Paper suggests:
“Use multimodal pain management strategies, including regional anesthesia and non-opioid analgesics, to control pain without compromising recovery.
Monitor closely for complications such as pneumonia or hemodynamic instability, intervening promptly to mitigate risks.
Collaborate with physiotherapists to implement early mobility programs, reducing the risk of deconditioning and promoting recovery.”
A multidisciplinary team proficient in geriatric trauma care leads to better outcomes. This may require transfer to a trauma center.
This white paper reminds us that age is just a number; frailty is a better predictor of morbidity and mortality after trauma.
“Frailty, characterized by reduced physiological reserve and increased vulnerability to stressors, is a significant factor influencing recovery from trauma. Individuals with frailty may experience slower healing, higher rates of complications, and longer hospital stays. Tools such as the Clinical Frailty Scale (CFS) and the Trauma-Specific Frailty Index (TSFI) have been developed to assess frailty systematically, enabling clinicians to predict outcomes and guide treatment decisions.”
