Ruptured Splenic Artery Aneurysm: Rare Cause of Shock Diagnosed with Bedside Ultrasound.

Splenic artery aneurysm rupture is rare and potentially fatal. It has largely been reported in pregnant patients and typically not diagnosed until laparotomy. This case reports a constellation of clinical and sonographic findings that may lead clinicians to rapidly diagnose ruptured splenic artery aneurysm at the bedside. We also propose a rapid, but systematic sonographic approach to patients with atraumatic hemoperitoneum causing shock. It is yet another demonstration of the utility of bedside ultrasound in critically ill patients, specifically with undifferentiated shock.

United States emergency department visits coded for intimate partner violence.

BACKGROUND: Limited information exists about medical treatment for victims of intimate partner violence (IPV). OBJECTIVE: Our aim was to estimate the number of emergency department (ED) visits and subsequent hospitalizations that were assigned a code specific to IPV and to describe the clinical and sociodemographic features of this population. METHODS: Data from the Nationwide Emergency Department Sample from 2006-2009 were analyzed. Cases with an external cause of injury code of E967.3 (battering by spouse or partner) were abstracted. RESULTS: From 2006-2009, there were 112,664 visits made to United States EDs with an e-code for battering by a partner or spouse. Most patients were female (93%) with a mean age of 35 years. Patients were significantly more likely to reside in communities with the lowest median income quartile and in the Southern United States. Approximately 5% of visits resulted in hospital admission. The mean charge for treat-and-release visits was $1904.69 and $27,068.00 for hospitalizations. Common diagnoses included superficial injuries and contusions, skull/face fractures, and complications of pregnancy. Females were more likely to experience superficial injuries and contusions, and males were more likely to have open wounds of the head, neck, trunk, and extremities. CONCLUSIONS: From 2006 to 2009, there were approximately 28,000 ED visits per year with an e-code specific to IPV. Although a minority, 7% of these visits were made by males, which has not been reported previously. Future prospective research should confirm the unique demographic and geographic features of these visits to guide development of targeted screening and intervention strategies to mitigate IPV and further characterize male IPV visits.

The use of technology to reduce radiation exposure in trauma patients transferred to a level I trauma center.

BACKGROUND: Patients with traumatic injuries transferred from rural hospitals to tertiary centers in West Virginia frequently undergo repeat computed axial tomography (CT) imaging upon arrival. The traditional method of sending images on a compact disc (CD) with EMS can be unreliable due to software incompatibility, CD malfunction, or misplacement of the CD. Given the known risks associated with ionizing radiation, physicians are increasingly aware of the need to avoid unnecessary CT imaging. Image storage applications such as ImageGrid provide a means to store images securely without the issues and inherent problems of a CD. These images can be uploaded at the referring hospital and may be viewed from any computer at the receiving facility, by multiple providers--even prior to patient arrival. The goal of this study was to determine if utilizing ImageGrid compared to traditional data transfer by CD resulted in a decrease in the amount and type of images obtained in the initial Emergency Department (ED) evaluation at the tertiary center. METHODS: We analyzed data from the Jon Michael Moore Trauma Registry for patients transferred to the Emergency Department at WVU Hospitals from an outside facility. Two study periods were reviewed; prior to ImageGrid implementation and after implementation of the system. Medical records of all patients admitted to the Trauma Surgery Service after a trauma system activation in the ED were reviewed during these time periods. Number and type of CT studies obtained in the Emergency Department were recorded for analysis. RESULTS: In the month of July 2010, 183 patients were admitted to the Trauma Surgery service after trauma team activation. Transfers from referring hospitals accounted for 77 of the 108 (42.1%). WVU Hospitals implemented ImageGrid during 2011. In July 2012, 243 patients were admitted to the Trauma Service, of which 105 (41.1%) were transfer patients. After implementation of ImageGridTM there was a significant decrease in the number of repeat CT Scans of the brain (19/27 [70.4%] vs. 18/40 [45.0%], p < .05), as well as CT scans of the chest, abdomen or chest/ abdomen/pelvis (9/18 [50.0%] vs. 2/23 [8.7%], p < .05). CT of the face showed a decreasing trend (5/9 [55.6%] vs. 1/9 [11%], p > .05 [p = 0.06]), but did not achieve statistical significance. After implementation of ImageGrid there was a marked decrease in total CT scans repeated (46/79 [58.2%] vs. 28/107 [26.2%], p < .05). CONCLUSION: In West Virginia, the use of image archival systems such as ImageGrid appears to result in less repeat CT imaging upon arrival at a tertiary trauma center. Given risks associated with ionizing radiation and costs of repeat imaging the benefits have important implications for patient safety and cost containment.

Acute arthritis of the hip--case series describing emergency physician performed ultrasound guided hip arthrocentesis.

We report two cases of acute hip arthritis where arthrocentesis was able to be performed rapidly, at the bedside by the emergency physician using ultrasound guidance, expediting diagnosis and patient care. In the first case, the patient, who was 23 weeks pregnant, was diagnosed with septic hip arthritis, taken for operative washout of the joint and did very well postoperatively with no pregnancy or other complications. In the second case, the patient was determined to have a noninfectious etiology and also did well. Skilled ultrasound guidance allows hip arthrocentesis to be performed by the treating clinician, decreasing the time to diagnosis and definitive care.

The treatment of cutaneous abscesses: comparison of emergency medicine providers' practice patterns.

INTRODUCTION: Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting. METHODS: Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED. RESULTS: In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation. CONCLUSION: Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies.

Generational influences in academic emergency medicine: structure, function, and culture (Part II).

Strategies for approaching generational issues that affect teaching and learning, mentoring, and technology in emergency medicine (EM) have been reported. Tactics to address generational influences involving the structure and function of the academic emergency department (ED), organizational culture, and EM schedule have not been published. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic EM. Understanding generational characteristics and mitigating strategies can address some common issues encountered in academic EM. By understanding the differences and strengths of each of the cohorts in academic EM departments and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.

Radiation exposure in emergency physicians working in an urban ED: a prospective cohort study.

OBJECTIVE: The National Council on Radiation Protection (NCRP) limits health care-associated occupational exposures to radiation to 5000 mrem/y. Previous studies suggested that emergency physicians were not exposed over this limit. Their relevance to contemporary practice is unknown. We hypothesized that emergency physicians are currently exposed to radiation levels above the NCRP limits. METHODS: This prospective cohort study was conducted at an urban, academic, level I trauma center emergency department (ED). Thermoluminescent dosimeter radiation badges were placed on the torso and ring finger of all physicians staffing the ED during May 2008. Thermoluminescent dosimeter badges were affixed to 8 portable phones that are carried by physicians in the ED 24 hours a day. At the end of the study period, exposure dose for each subject was estimated. RESULTS: Seventy-five physicians enrolled in the study; 41 residents worked a median of 94 hours and 34 attendings worked a median of 54 hours. Compliance for physician badge wearing was 99%, ring wearing was 98%, and phone wearing was 100%. Two subjects had detectable levels of radiation on their torso thermoluminescent dosimeters of 4 and 1 mrem, respectively. One phone badge had a detectable level of 1 mrem. The annual extrapolated exposure for the subject with the highest radiation level would have been 50 mrem, below the 5000 mrem exposure limit for health care workers. CONCLUSION: Emergency physicians working in an urban, academic, level I trauma center ED do not appear to be at risk of exceeding the NCRP dose limits for ionizing radiation exposure to their torso or extremities.

Hyponatremia in runners requiring on-site medical treatment at a single marathon.

STUDY OBJECTIVE: Literature reports indicate an increasing number of cases of hyponatremia in athletes participating in moderate endurance events such as standard marathons. In this study, we evaluated the incidence of hyponatremia in marathon finishers requiring medical treatment on-site and attempted to assess the contribution of fluid type ingested and nonsteroidal antiinflammatory drug (NSAID) use to the development of hyponatremia. METHODS: We examined a prospective, convenience sample of runners requiring intravenous hydration at the final medical tent of a standard marathon course and a comparison group of finishers who did not require intravenous hydration. After giving informed consent, subjects had blood drawn and answered a questionnaire regarding fluid intake on the course and NSAID use before the race. Blood samples were analyzed on-site for serum sodium values as well as other hematologic parameters. RESULTS: Fifty-one subjects requiring intravenous hydration as well as 11 subjects who did not were enrolled. Three subjects (5.6%; 95% CI, 0-11.9%; missing = 8) in the intravenous hydration group had serum sodium less than 130 mEq/L. None of the three runners suffered neurologic or pulmonary consequences and only one required overnight hospital admission for hydration. The small number of hyponatremic subjects precluded the analysis of the role of fluid type or NSAID use in the development of hyponatremia or the development of a model for prediction. CONCLUSION: This study found a 5.6% incidence of hyponatremia in marathon runners requiring medical treatment.