Acetabular fractures: what radiologists should know and how 3D CT can aid classification.

Correct recognition, description, and classification of acetabular fractures is essential for efficient patient triage and treatment. Acetabular fractures may result from high-energy trauma or low-energy trauma in the elderly. The most widely used acetabular fracture classification system among radiologists and orthopedic surgeons is the system of Judet and Letournel, which includes five elementary (or elemental) and five associated fractures. The elementary fractures are anterior wall, posterior wall, anterior column, posterior column, and transverse. The associated fractures are all combinations or partial combinations of the elementary fractures and include transverse with posterior wall, T-shaped, associated both column, anterior column or wall with posterior hemitransverse, and posterior column with posterior wall. The most unique fracture is the associated both column fracture, which completely dissociates the acetabular articular surface from the sciatic buttress. Accurate categorization of acetabular fractures is challenging because of the complex three-dimensional (3D) anatomy of the pelvis, the rarity of certain acetabular fracture variants, and confusing nomenclature. Comparing a 3D image of the fractured acetabulum with a standard diagram containing the 10 Judet and Letournel categories of acetabular fracture and using a flowchart algorithm are effective ways of arriving at the correct fracture classification. Online supplemental material is available for this article.

The Effect of Numbered Jerseys on Directed Commands, Teamwork, and Clinical Performance During Simulated Emergencies.

ABSTRACT: Communication and teamwork are essential during inpatient emergencies such as cardiac arrest and rapid response (RR) codes. We investigated whether wearing numbered jerseys affect directed commands, teamwork, and performance during simulated codes. Eight teams of 6 residents participated in 64 simulations. Four teams were randomized to the experimental group wearing numbered jerseys, and four to the control group wearing work attire. The experimental group used more directed commands (49% vs. 31%, p < .001) and had higher teamwork score (25 vs. 18, p < .001) compared with control group. There was no difference in time to initiation of chest compression, bag-valve-mask ventilation, and correct medications. Time to defibrillation was longer in the experimental group (190 vs. 140 seconds, p = .035). Using numbered jerseys during simulations was associated with increased use of directed commands and better teamwork. Time to performance of clinical actions was similar except for longer time to defibrillation in the jersey group.

The Best of Both Worlds: Eliminating Creatine Kinase-Muscle/Brain (CK-MB) Testing in the Emergency Department Leads to Lower Costs Without Missed Clinical Diagnoses.

The 2014 American Heart Association/American College of Cardiology (AHA/ACC) clinical guidelines recommend cardiac troponin as a superior biomarker to creatine kinase (CK) and creatine kinase-muscle/brain (CK-MB) for the detection of acute coronary syndrome (ACS), namely myocardial infarction and unstable angina. In April 2018, our Emergency Department (ED) transitioned from using standard troponin to using high-sensitivity troponin T, and adopted a clinical guideline consistent with the AHA/ACC. The guideline recommended high-sensitivity troponin T without CK/CK-MB testing in the majority of clinical situations, limiting CK/CK-MB testing to two specific clinical cases: 1) estimated glomerular filtration rate (eGFR) value <15 mL/min, or 2) recent acute coronary syndrome (ACS) event. Per our ED's policy, a "negative" troponin T was defined as being below the limit of detection (LOD) (i.e., <6 ng/L); such a value obtained at least 3 hours after symptom onset "ruled out" an ACS event and did not require a repeat troponin. The goal of this retrospective study was to determine whether the guideline limiting CK-MB testing missed clinically-significant cardiac outcomes (ACS or new diagnosis of coronary artery disease [CAD]) or was associated with mortality. Pre-implementation data (July 1, 2017 - December 31, 2017) was compared with post-implementation data (July 1, 2018 - December 31, 2018). After guideline introduction, CK/CK-MB ordering decreased by nearly 90%, while troponin ordering increased by nearly 20%, likely due to the introduction in June 2018 of high-sensitivity troponin T, which yielded numerous intermediate/indeterminate-range results that prompted repeat testing. Fewer than 1.5% of patients with a "negative" troponin (below the LOD) and a "positive" CK-MB (above the upper limit of normal [ULN]) had ACS or new-diagnosis CAD; patients with either diagnosis did not expire during their hospital stay or within 30 days of their index visit. CK-MB Index, which has a higher specificity than CK, only found ACS or new CAD among 0.8% of positive results. Considering both decreased CK/CK-MB and increased troponin ordering, the net annual direct cost savings in cardiac biomarker testing was extrapolated to $12,700. Had our institution not transitioned to higher cost high-sensitivity troponin ($2.054/unit) from standard troponin ($1.65/unit), and had the rate of troponin ordering increased solely proportionate to the rate of ED visit increase (2% year-over-year) rather than increase nearly 20% (likely due to the transition to high-sensitivity troponin), then the total six-month direct costs on troponin testing would have been $14,632 instead of $21,267.12, and annual direct cost savings would have been $18,945.80 instead of $12,700. The new ED clinical guideline did not result in a significant number of missed ACS or new-diagnosis CAD, and was associated with direct cost savings. These savings probably underestimate total savings, as the reduced number of "false-positive" CK-MB results likely prevented additional costs, such as hospitalization, specialty consultation, coronary calcium CT, echocardiogram, cardiac stress test, and coronary artery catheterization.