Predicting which blunt abdominal trauma patients have mesenteric or bowel wall injuries early in their ED course will decrease morbidity and mortality. It is also a challenge even in the age of advanced CT imaging. This study from India looks at the Bowel Injury Prediction Score as a possible means to catch these injuries early in the course of care. The score uses white blood cell count over 17,000 (1 point), abdominal tenderness at the time of presentation(1 point), as well as a McNutt's scoring scale grade 4 (1 point) (table). The study found those with a score greater than 2 (out of 0-3) were much more likely to have bowel or mesenteric injury at time of laparotomy. Tenderness and CT findings were more likely to be predictive of bowel injury than WBC greater than 17,000. “BIPS had 94.5% sensitivity, 72% specificity, 88% PPV, and 86% NPV for identifying patients with sBBMI.”
My take away is an abnormal CT scan or significant tenderness of presentation warrant concern for mesenteric or bowel wall injury and surgical evaluation is appropriate for these patients. An elevated or normal white blood cell count isn't helpful in these patients. Surgeons may use this scale to help them decide if a patient warrants a trip to the operating room
| GRADE | FINDING |
|---|---|
| 1 | Isolated mesenteric contusion without associated bowel wall thickening or adjacent interloop fluid collection |
| 2 | Mesenteric hematoma?<?5 cm without associated bowel wall thickening or adjacent interloop fluid collection |
| 3 | Mesenteric hematoma?>?5 cm without associated bowel wall thickening or adjacent interloop fluid collection |
| 4 | Mesenteric contusion or hematoma (any size) with associated bowel wall thickening or adjacent interloop fluid collection |
| 5 | Active vascular or oral contrast extravasation bowel transaction or pneumoperitoneum |
This review reminds us that discharging emergency department patients with abnormal vital signs is a risk for the patient and the provider. The more abnormal vital signs that are present, the higher the risk of adverse event and subsequent return to the emergency department.
“Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians.”
Always address abnormal vital signs in your medical decision making portion of the chart and be very wary of discharging anyone with tachycardia or other abnormal vital signs.
In this systemic literature review of orthopedic injuries identified in intimate partner violence (IPV) the authors remind us that finger, hand, and especially isolated ulnar fractures are very commonly associated with IPV. When we see these injury patterns extra effort is required to determine if IPV is involved.
| Citation | **Bhandari et al.**3 | **Khurana et al.**18 | **Loder et al.**12 | **Porter et al.**13 | **Kavak et al.**7 | **Thomas et al.**17 |
|---|---|---|---|---|---|---|
| Division of injury locations | Fingers, wrist, shoulder dislocation, humerus fracture | Finger, hand, wrist, forearm, elbow, humerus, shoulder | Finger, hand, wrist, forearm, elbow, humerus, shoulder | Radius/ulna, humerus, upper extremity, right/left | Phalanx, radius, ulna (diaphysis/metaphysis, distal/proximal) | Phalanges (distal/medial/proximal), hand/finger, forearm, arm/shoulder right/left |
| Most common UEF location | Fingers (n = 11) | Finger (34.3%) | Finger (9.9%) | Radius and ulna (n = 80; 5.9%) | Ulna (14.5%) | Finger (46%) |
| Most common injury type‡ | Musculoskeletal sprains (all n = 21; 28% back n = 7; neck n = 6) | UEF (27.2%) | Contusions/abrasion (43.4%) | Rib fracture (17.5%) | Soft-tissue lesions (n = 1,007, 82.2%) | UEF (52%) |
* IPV = intimate partner violence, UEF = upper extremity fracture, and UEI = upper extremity injury.
† Summary table demonstrating the location prevalence of UEIs caused by cases of IPV. Fractures were quantified separately from other UEIs in this specific table.
‡ In all included articles the most common injury type was an injury to the head or neck; these are excluded because of the study aim.
This retrospective study of Swiss trauma patients looked at blood gas oxygen levels within 3 hours of arrival to the trauma bay in severely injured patients over age 16. When comparing hypoxic, hyperoxic and normo-oxic patients there was no difference in 28 day mortality. Those with above normal oxygen levels tended toward longer hospital stays. The above normal oxygen cohort also were more likely to be intubated in the field.
This study fits with others showing around 20% of trauma patients arrive to our trauma bays over oxygenated. More research is needed to see the impact this has on care. Be mindful of over oxygenation especially in intubated trauma patients.
Deciding who needs exposure to radiation after blunt head injury has been looked at by both the Canadian Head Injury Guidelines as well as NEXUS. This website has excellent graphics outlining the rules. Note age over 65 alone is predictive of significant intracranial injury. All recent studies indicate age over 65 even with a low suspicion mechanism such as fall from standing is still a significant risk for intracranial pathology.
A study looking at patients over age 65 with head injuries from falls assessed the association of alcohol use with severity of injury. The alcohol use was self-reported which does limit the findings. The study found “Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use.” Those daily drinkers had a higher incidence of intercranial injuries.
The authors concluded: “Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.”
A reminder of two validated tools used to determine the need for cervical spine imaging in adult blunt trauma patients. A recent meta analysis concluded:
“Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.”
A just released study published in the Lancet gives us guidance on which pediatric blunt trauma patients need cervical spine imaging. Age range was 0-17 years.
“Out of 22,430 children included in the study, 433 (1.9%) were found to have Cervical spine injury (CSI). The study identified 4 high risk factors for CSI to be used to triage children to CT (12% risk for a cervical spine injury):
In children without high-risk findings, 5 additional findings identified children with intermediate, non-negligible risk of CSI (3.6% risk of a cervical spine injury):
This article from JAMA is targeted at inpatient management of asymptomatic hypertension, however, it’s a great reminder that “hypertensive urgency” is not an entity. We should be treating the patient and not the numbers. Gradual, out patient lowering of asymptomatic hypertension is the safe and proper way to approach this. Spread the word to your friends in primary care, urgent care, dental, and other office based practices.
This article serves as a great reminder that our older patients are on a significant amount of medications and many of these medications effect cognition. Cognitively impaired patients are at risk of medication errors. High risk medications in older patients include anticoagulants, opioids, anticholinergics, hypoglycemic/insulin and sedating medications. The authors found:
It is important to ask how the patient takes (or doesn’t take) their medications as well as other social determinate of health such as living alone.
A cut-off of 35mm on CT scan has been shown to be predictive of which traumatic pneumothoracies require thoracostomy tube placement vs. safety of observation. This retrospective study looked at chest X-ray findings to see if there was a similar size cut-off where patients could be safely observed rather than undergo this invasive procedure. They found 38mm was the size over which observation failed. Of note, lactic acidosis and need for supplemental oxygen also predicted the need for chest tube placement
In this prospective, observational study of trauma patients with isolated head trauma, 62% of patients developed post-intubation hypotension. Comparing patients receiving hypertonic saline, vasopressors, crystalloid, or blood those receiving hypertonic saline and vasopressors had less post-intubation hypotension.
TBI patients who develop hypotension have worse outcomes. This study reminds us the use of vasopressors in trauma patients to maintain blood pressure is appropriate in the correct circumstances.
The Infectious Disease Society of America in 2023 recommended a single dose of an aminoglycoside for uncomplicated cystitis treatment in those with resistance or other contraindications to first line oral agents who were otherwise well enough to be discharged. This very small study (13 participants) suggest this strategy works for complicated (“male sex, urinary flow obstruction, renal failure or transplantation, urinary retention, or indwelling catheters”) cystitis patients who could otherwise be discharged home.
According to this study, no TXA 2g bolus was not found to increase the number of seizures in TBI pts.
TXA has been shown to improve mortality in inter cranial hemorrhage trauma patients if given within 2 hours. TXA is also known to lower seizure threshold. This study was a secondary analysis of a larger study comparing placebo to 1 g TXA bolus plus 8 hour infusion or 2g bolus TXA in the prehospital setting. There was no difference in the number of pts experiencing seizure or outcome in those receiving the 2g bolus of TXA.
Deciding which pulmonary embolism patient needs thrombolytics/catheter based intervention is a shared decision among emergency physicians, intensivists, interventionalists, hospitalists, and the patient/family. This article provides evidence to help guide this decision. Keep in mind “The use of either CDL or catheter-based embolectomy in patients with intermediate-risk PE has, thus far, been correlated only with more rapid improvement of RV dysfunction than anticoagulation alone, not short- or long-term clinical or functional outcomes.”
"1. Massive (AHA) or high risk (ESC): Hypotension, defined as a systolic blood pressure <90 mm?Hg, a drop of >40 mm?Hg for at least 15 minutes (this latter criterion may be difficult to ascertain in some clinical circumstances), or need for vasopressor support, identifies these patients. They account for ?5% of hospitalized patients with PE and have an average mortality of ?30% within 1 month.
2.Submassive (AHA) or intermediate risk (ESC): RV strain without hypotension (see above) primarily identifies these patients. RV strain includes RV dysfunction on computed tomography pulmonary angiography or echocardiography (RV/left ventricular [LV] ratio >0.9)6,7 or RV injury and pressure overload detected by an increase in cardiac biomarkers such as troponins or brain natriuretic hormone.
3.Low risk (ESC and AHA): These patients do not meet criteria for submassive (AHA) or intermediate-risk (ESC) PE"
The Bova score has been validated to predict mortality and complications in hemodynamically stable patients with intermediate to high-risk pulmonary embolisms. There is some literature on using the Bova score to decide on thrombolytics/interventional therapy as well.
Scoring Criteria:
Interpretation:
Patient struck in left eye. The patient was asked to look up during exam and this is the finding. What imaging modality would you order if so inclined, what is the injury, and what is the disposition/plan?
192 trauma patients who were receiving pre-hospital fentanyl for moderate to severe pain were randomized to placebo or intranasal 50 mg ketamine as an adjunct for pain control. There was no difference between the two groups in decrease in pain scale.
The authors concluded: “In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.”
The systematic review of presyncope literature found that presyncope should be treated the same as syncope in terms of work up and disposition.
“In conclusion, the prevalence of short-term serious outcomes among ED patients with presyncope ranges from one in four to one in 20, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as that of ED syncope.”
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