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.”
Two recommendations from the recent GRACE 4 publication in Academic Emergency Medicine to consider:
1. Use phenobarbital along with benzodiazepines in patients with moderate to severe alcohol withdrawal. The evidence isn’t robust but is positive when compared to benzos alone.
2. Adults with alcohol use disorder can benefit from anti-craving medications such as naloxone and gabapentin at time of discharge.
A prospective European study of patients over age 65 presenting with a ground level fall obtained troponin levels to ascertain if myocardial infarction was a cause of the ground level fall. Troponin levels were elevated in a majority of patients however only 0.5% were defined as having a myocardial infarction. Of the 3% who died within 1 year, troponin was found to be higher than those that survived the one-year study period. The authors concluded “Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1?year.”
Appropriately, a great deal of time and energy is being expended to educate on the use of tourniquets to prevent mass hemorrhage. Are the current generation of tourniquets the best that we can have? These authors performed a Delphi study to assess needs with tourniquet design.
They concluded the next generation of tourniquets should have the following: “Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions.”
This study used the modified Brain injury Guidelines retrospectively to assess whether the guidelines would have saved transfers to their level one facility safely. They concluded the guidelines would have effectively prevented unnecessary mBIG 1 and mBIG2 transfers with no patient harm.
TABLE 1 - Modified Brain Injury Guidelines Radiologic Stratification, as per Kahn et al.
| mBIG 1 | mBIG 2 | mBIG 3 | |
|---|---|---|---|
| Skull fracture | No | Non-displaced | Displaced |
| SDH | ?4 mm | 4–7.9 mm | ?8 mm |
| EDH | No | No | Yes |
| SAH | ?3 sulci and <1 mm | Single hemisphere or 1–3 mm | Bihemisphere or >3 mm |
| IVH | No | No | Yes |
| IPH | ?4 mm | 4–7.9 mm | ?8 mm or multiple |
EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage.
In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five underwent neurosurgery. The authors concluded:
“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”
It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.
This Delphi study and companion editorial highlight current thought on frailty screen in emergency department patients. Key takeaways are:
Emergency departments should be instituting procedures that incorporate screening older patients for frailty. These references are a good starting point.
On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management.
The reference is a nice review of these fractures
This very small study looked at the utility of using IV contrast media to enhance abdominal sonography in identifying injuries in blunt abdominal trauma patients. The comparison was CT scanning of the abdomen to identify injuries. The study concluded:
“With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.”
To me, this is a limited study and the technique is not ready for wide spread use but further study is warranted.
-668ade5e780f0.jpg)
