Crowned dens syndrome is an acute inflammatory disease caused by deposition of calcium pyrophosphate dihydrate crystals or hydroxyapatite crystals in the soft tissue and ligaments surrounding the dense. Patient presentation is severe pain in the neck and base of the skull, low grade fever, and elevated inflammatory markers. It is most commonly seen in elderly females. Ct scan is the gold standard for diagnosis. Once meningitis and other significant infectious process has been excluded, treatment is anti inflammatory medications including steroids.
Another large database evaluation of the use of etomidate vs. ketamine as an induction agent for intubation found a trend toward higher mortality in the etomidate group. Even when trying to control for steroid use (to control for etomidate’s possible adrenal suppression), etomidate had a higher mortality rate.
A well done study that adds to the chorus advocating for choosing ketamine when looking for a hemodynamically neutral induction agent.
In this randomized trial of restrictive oxygen (arterial oxygen sat of 94% ) vs. liberal oxygen (12-15 L of O2 per minute) for 8 hours after traumatic injury there was no difference in mortality or major respiratory complications at 30 days between the two groups.
Further evidence that managing hypoxia is important but over oxygenation at best offers no benefit and may add harm.
This prospective observational study looked at patients with liver lacerations and active contrast extravasation who either had immediate embolization vs. observation. After matching for age, injury score etc. the observation first approach did as well as those who had immediate embolization.
This study tried to expand upon what they describe as the classic triad of signs to diagnose ruptured AAA “(1) abdominal pain, (2) hypotension and (3) a pulsatile abdominal mass”. They tested these against the _modified abdominal aortic aneurysm rupture signs. “_The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding”. The MARS did slightly better in identifying ruptured AAA retrospectively. For me, this doesn’t add a great deal of help in making this can’t miss diagnosis and further work is necessary.
Fall from a height of 6 feet with back pain. Plain film shown. What is the diagnosis? Any further imaging indicated? Treatment? Disposition?
As a reminder, prescribing medications to older patients should be done with caution because of changed physiology, co-morbid conditions and other currently used medications. The Beers Criteria is a helpful list of medications that may cause trouble for your older patients. https://www.guidelinecentral.com/guideline/340784/#section-2776198 is a list of medications to either avoid or prescribe carefully in this patient population.
Pay particular attention to medications that have anticholinergic properties as they cause change in mental status and increase the risk for falls.
From all of us at UMEM, Happy Thanksgiving!!
We are incredibly Thankful for each of you and all that you do to care for patients and their families.
We are Thankful for those legends who have blazed the path in EM like Greg Henry who the EM community lost yesterday. Our thoughts are with his family. Thank you Dr. Henry for inspiring so many of us. Our pearls today are two of his famous quotes:
“Medicine is show business for ugly people.”
“You don’t go to Disney and see Mickey taking a smoke break. You have to be on when you are on shift”
It is important for trauma and emergency care providers to understand what our patients experience prior to arrival in our clean, safe, and structured emergency department. It is also vitally important that we are involved in training and education in the pre-hospital environment. A group in the United Kingdom is challenging the age old “wisdom” that post-motor vehicle crash extrication should be slow, methodical, and work to have absolutely no movement in the spinal canal. Spinal immobilization and slow extrication instead of rapid resuscitation appears to be bad for patients. Based on several of their ground breaking papers they have published a 14 point recommendation of patient extrication post motor vehicle collision. Here are two important tenets they propose. For an in-depth discussion check out November 14, 2024 / CPD, Podcasts, Roadside to Resus.
The authors looked at 51 patients intubated with both anterior and posterior cervical collar in place and measured the degree of movement within the spine during intubation. They repeated this process in 51 additional patients with just the posterior portion of the collar in place. They found there was one degree of difference in movement between the two groups. This adds evidence that removing the anterior portion of the collar is safe when intubating trauma patients.
This retrospective study illustrates that the use of CT scanning to identify injury in gun shot wounds to the abdomen is not sensitive or specific enough to obviate the need for laparotomy. “Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy.” If there is clear indication to go to the OR, stopping in CT does not add any benefit.
Administration of prehospital TXA was found to improve 28 day mortality and decrease the amount of blood required to be transfused without any increased risk of thromboembolism or seizure. Two grams of TXA was superior to one gram and no TXA.
In this small retrospective study comparing outcomes before and after a prehospital blood administration protocol for penetrating trauma was initiated, the authors found improved survival in those receiving prehospital blood despite a five minute longer on scene time in those receiving blood. Also note TXA was part of the blood protocol but not the control group.
This study used the New York State hospital discharge database to look for factors associated with being the victim of repeat gun violence.
Unanswered questions include: is it similar in other areas, what interventions at the patient level could prevent this, what other patient level factors (substance use, etc) are involved, however, this is a good start in looking at this preventable disease.
Recent studies continue to highlight that Black, Native American, female, uninsured and Medicaid patients receive disproportionately more substance use screening when they are trauma patients. The authors of this paper point out that this inappropriate application of screening leads to missed opportunities.
“Screening patients for drug and alcohol use following injury is an evidence-based practice that can trigger wraparound care, such as brief substance use interventions, to prevent reinjury. Adolescents who consume alcohol but are not screened for alcohol use have 2- to 3- fold greater likelihood of reinjury compared with those who were screened and received a brief intervention.”
Hypertension in the ED comes in two varieties: emergency and asymptomatic (not urgency!). From this position statement: “Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting.”
Conversely, asymptomatic does not require urgent, aggressive management. “Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question.”
Without target organ involvement, we do not need to be initiating IV medications or trying to treat the numbers
There is uncertainty if adding cryopercipitate empirically to all mass hemorrhage protocols has any benefit to mortality, need for transfusion, or any other meaningful outcome. This small study suggests it does not and that we should save the addition of cryopercipitate to those with lab proven low fibrinogen levels.
For penetrating neck trauma:
Does it violate the platysma if no, close wound and discharge
If yes, are there any hard signs of injury like enlarging hematoma, air from the wound, difficulty swallowing, blood in the airway, respiratory distress then to the OR
If no, Ct angio of the neck. If negative and no other findings admit for observation or discharge. If positive, to the OR. If equivocal, endoscopy and broncoscopy.
No longer think about the zones of the neck. Treat them all the same.
This article serves as a reminder that trauma can and will precipitate adrenal insufficiency and crisis in those trauma patients who are on steroids pre-injury. Look for prednisone or hydrocortisone as well as autoimmune or rheumatologic diseases on pre-injury medication list and history. Consider the diagnosis in trauma patients with refractory hypotension not responsive to vasopressors. Replacement therapy with hydrocortisone is the therapy.
