Emergency Abdominopelvic Injuries.

The presentation of traumatic abdominopelvic injuries in sport can range from initially benign appearing to hemorrhagic shock. A high clinical suspicion for injury, knowledge of the red flags for emergent further evaluation, and familiarity with the initial stabilization procedures are necessary for sideline medical providers. The most important traumatic abdominopelvic topics are covered in this article. In addition, the authors outline the evaluation, management, and return-to-play considerations for the most common abdominopelvic injuries, including liver and splenic lacerations, renal contusions, rectus sheath hematomas, and several others.

Training and Practice Settings of Physicians Dual-Certified in Emergency and Sports Medicine.

ABSTRACT: Survey study of training and practice paradigms and job satisfaction of dual-boarded emergency medicine (EM) and sports medicine (SM) physicians. The REDCap survey was sent to 193 American Board of EM members who hold a Certificate of Added Qualification in SM. A total of 124 EM/SM physicians responded (67.5% male). More than 70% completed three-year residencies while only 28.5% had an EM/SM residency faculty. One-quarter delayed fellowship after residency 6.45 years on average. Regarding their first job after fellowship, 27.6% practiced only EM, 54.5% practiced both EM and SM, and 12.2% practiced only SM. Regarding their current job, 29.1% practice only EM. 47.3% practice both EM and SM, and 20.9% practice only SM. Only 13.9% and 9.9% indicated they are unhappy with their first job and current job, respectively. There is significant variability in practice settings for EM/SM physicians with the overwhelming majority being happy with their career choices.

Consider Going Decaf: An Intentional Caffeine Overdose in the Emergency Department.

BACKGROUND: Caffeine (1,3,7-trimethylxanthine) is a naturally occurring compound found in plants and is the most utilized drug in the world. An estimated 89% of U.S. citizens and 80% of people worldwide consume caffeine on a regular basis. The prevalence of caffeine supplementation by individuals has been increasing in body-weight regulation (e.g., weight loss, body building). When used in excessive amounts it can precipitate serious health consequences, including death. Given this, and the ease of accessibility, caffeine has been seen in intentional overdose. However, suicide attempts via caffeine overdose are rare. In 2017, the American Association of Poison Control Centers reported 3765 cases of caffeine overdose, of which 650 were intentional and none resulted in death from caffeine alone. An ingestion of 5 g (80-100 mg/kg) is likely to prove fatal. CASE REPORTS: We present the case of a suicide attempt via caffeine with a reported 20-g overdose, which would be an estimated blood caffeine level of 427.1 mg/L. The patient was given activated charcoal and treated for symptomatic tachycardia and diaphoresis. He was ultimately evaluated by Psychiatry and was discharged home with no adverse outcomes from his intentional overdose. We also examine the physiology of the potential adverse effects of caffeine use and the current literature related to caffeine overdoses. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Caffeine is consumed by billions of individuals globally. It is rarely associated with death, but can cause a variety of adverse effects including tachydysrhythmias, hypokalemia, seizures, and rhabdomyolysis. Caffeine overdoses should be treated immediately with activated charcoal if within the appropriate timeframe of 1-2 h post-ingestion, and special attention should be given to the cardiovascular effects of caffeine, as tachydysrhythmias may prove fatal.

Break up the band: Laparoscopic Adjustable Gastric Banding-associated Discitis and Osteomyelitis.

Obesity is an epidemic that adversely affects millions of Americans. In 2017, the Center for Disease Control and Prevention reported that 93.3 million Americans suffer from obesity.1 Many individuals have undergone laparoscopic adjustable gastric banding (LAGB) procedures in order to lose weight. The procedure is thought to be safe with complication rates reported as low as 1.6% following surgery.2 We present a case of LAGB-associated discitis and osteomyelitis 20 years after placement and examine the current literature on the complication rates of bariatric surgery along with the rare injuries following LAGB placement.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study.

INTRODUCTION: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs. METHODS: We queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule. RESULTS: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging. CONCLUSION: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.

Gluteal Burns from a Car Seat Heater in a Neurologically Intact Patient: A Case Report.

BACKGROUND: Car seat heaters are an increasingly common amenity in vehicles in the United States, but they have been shown to place neurologically impaired patients at risk for significant burns. CASE REPORT: We discuss the case of a neurologically intact and otherwise healthy 49-year-old man who presented to the Emergency Department with second-degree gluteal and posterior upper thigh burns after using a car seat warmer for 8 consecutive hours. At no point during the course of his drive did he experience discomfort beyond feeling slightly warm. The patient was treated with supportive therapy and standard wound care, and he had a full recovery after 10 days. We review the pathophysiology of burns and discuss how seat heaters can place even neurologically intact patients at risk for significant burn injuries. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is the first published report of a neurologically intact patient sustaining significant burns from the use of a car seat heater. This case illustrates that burn injuries can develop after prolonged exposure even at low temperatures. Emergency physicians should perform a careful skin examination on all patients presenting with gluteal discomfort in whom a history of car seat warmer use is obtained.

The Diagnosis and Management of Facial Bone Fractures.

Appropriate medical care for a patient with a facial fracture can not only optimize aesthetic outcomes but also prevent the potential morbidity and mortality of delayed treatment. In this article, we focus on the clinical presentations, physical examination findings, diagnostic imaging, consultations, and follow-up that patients with facial fractures need related to their emergency department management. Specifically, we address the nuances of evaluating frontal, orbital, nasal, maxillofacial, and mandibular fractures.

Don't Just Blame it on the Veins: An Update on Vascular Exertional Limb Pain.

Exertional limb pain is a common problem encountered in recreational and competitive athletes. Affecting both the upper and lower extremities, this broad entity can be musculoskeletal, vascular, neurologic, oncologic, or infectious in origin. This article focuses on the vascular causes of exercise-related extremity pain, which encompass a cadre of elusive diagnoses. Specifically, we examine arterial endofibrosis, popliteal artery entrapment syndrome, and chronic exertional compartment syndrome of both the upper and lower extremities. For each of these conditions, we offer updates regarding the respective epidemiology, common signs and symptoms, worthwhile diagnostic modalities, and pertinent treatment options, all based on evidence and reports published over the past year.

Evaluation and Management of Rotator Cuff Tears: a Primary Care Perspective.

PURPOSE OF REVIEW: To provide a primary care perspective regarding the evaluation and management of shoulder pain and rotator cuff tears. RECENT FINDINGS: In the primary care setting, rotator cuff pathology is commonly encountered. Information regarding the risks of oral medications for the management of the associated pain keeps mounting. Partial-thickness rotator cuff tears remain difficult to diagnose with a single imaging modality. Musculoskeletal education in medical schools and non-orthopaedic residency and fellowship training programs continues to be an area for additional improvement. In the primary care office, the initial evaluation of shoulder pain should include a thorough musculoskeletal evaluation in order to identify the source of the pain (e.g., shoulder, cervical spine, chest wall), as well as the development of an initial treatment plan. Access to imaging modalities such as ultrasound and MRI can vary depending on the resources available in the primary care setting. The identification of patients who may benefit from early surgical referral is imperative for optimizing outcomes.

Longitudinal Improvement in Balance Error Scoring System Scores among NCAA Division-I Football Athletes.

The Balance Error Scoring System (BESS) is a commonly used concussion assessment tool. Recent studies have questioned the stability and reliability of baseline BESS scores. The purpose of this longitudinal prospective cohort study is to examine differences in yearly baseline BESS scores in athletes participating on an NCAA Division-I football team. NCAA Division-I freshman football athletes were videotaped performing the BESS test at matriculation and after 1 year of participation in the football program. Twenty-three athletes were enrolled in year 1 of the study, and 25 athletes were enrolled in year 2. Those athletes enrolled in year 1 were again videotaped after year 2 of the study. The paired t-test was used to assess for change in score over time for the firm surface, foam surface, and the cumulative BESS score. Additionally, inter- and intrarater reliability values were calculated. Cumulative errors on the BESS significantly decreased from a mean of 20.3 at baseline to 16.8 after 1 year of participation. The mean number of errors following the second year of participation was 15.0. Inter-rater reliability for the cumulative score ranged from 0.65 to 0.75. Intrarater reliability was 0.81. After 1 year of participation, there is a statistically and clinically significant improvement in BESS scores in an NCAA Division-I football program. Although additional improvement in BESS scores was noted after a second year of participation, it did not reach statistical significance. Football athletes should undergo baseline BESS testing at least yearly if the BESS is to be optimally useful as a diagnostic test for concussion.

An evidence-based medicine curriculum implemented in journal club improves resident performance on the Fresno test.

BACKGROUND: Journal club is a standard component of residency education. Journal club focuses on review and interpretation of the medical literature with varying degrees of evidence-based medicine (EBM) education. OBJECTIVES: To evaluate learning of EBM principles with an EBM curriculum implemented as a component of journal club. EBM competency was established using the Fresno test, a validated 12-question instrument of short-answer and essay-style questions to assess competency in EBM. METHODS: An EBM curriculum was implemented that consisted of a focus on EBM topics (e.g., study validity, bias, confidence intervals, search strategies) using a structured journal club format using a peer instruction model. The Fresno test was used prior to and after the implementation of the first year of this curriculum to measure effectiveness of the intervention. A hierarchical multivariable model using generalized estimating equations was used to account for repeated measures in the primary outcome of change in total Fresno test score. RESULTS: The total test scores did not increase significantly (105.4 vs. 120.9, p = 0.058) in the before-after analysis. The only subscore showing improvement was interpretation of study validity (32.1 vs. 40.4 points, p = 0.03). Attendance was significantly associated with Fresno test score, with those attending ≥ 6/11 sessions (55%) scoring 28.2 points higher (p = 0.003), and those attending fewer than six sessions scoring only 1.9 points higher (p = 0.81) than in the preintervention group. CONCLUSION: An EBM curriculum implemented as part of journal club improves performance on the Fresno test among residents who attended at least six journal club sessions.

Tenosynovial Osteochondromatosis of the Flexor Hallucis Longus in a Division I Tennis Player.

Tenosynovial (extra-articular) chondromatosis (TC) is a condition characterized by the cartilaginous proliferation of synovial cells derived from the synovial lining of bursa and tendon sheaths. These lesions are often multinodular and most commonly present with complaints of swelling or pain. Treatment of TC primarily entails surgical excision. There are no known reports of TC in collegiate athletes. We present a case of TC in a Division I tennis player.

News flash: Old Mother Hubbard reports the cupboard is bare...time for the FDA to let droperidol out of the (black) box.

A quick way for a clinical pharmacist to eliminate himself or herself from "employee of the month" consideration is to mention the term medication shortage. Even with training geared toward maximizing resources, the cumulative disappearance of a plethora of medications for the treatment of nausea, vomiting, and/or primary headaches is almost too much for emergency medicine physicians to manage. With prochlorperazine, metoclopramide, promethazine, and ondansetron in increasingly short supply, it is time for the Food and Drug Administration to revisit droperidol's black box warning driven by QTc interval prolongation, given its questionable validity, and restore droperidol's place in the armamentarium of emergency medicine physicians.

Treating primary headaches in the ED: can droperidol regain its role?

OBJECTIVE: The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED). METHODS: A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively. RESULTS: Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia. CONCLUSION: The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED.

Exercise enhances myocardial ischemic tolerance via an opioid receptor-dependent mechanism.

Exercise increases serum opioid levels and improves cardiovascular health. Here we tested the hypothesis that opioids contribute to the acute cardioprotective effects of exercise using a rat model of exercise-induced cardioprotection. For the standard protocol, rats were randomized to 4 days of treadmill training and 1 day of vigorous exercise (day 5), or to a sham exercise control group. On day 6, animals were killed, and global myocardial ischemic tolerance was assessed on a modified Langendorff apparatus. Twenty minutes of ischemia followed by 3 h of reperfusion resulted in a mean infarct size of 42 +/- 4% in hearts from sham exercise controls and 21 +/- 3% (P < 0.001) in the exercised group. The cardioprotective effects of exercise were gone by 5 days after the final exercise period. To determine the role of opioid receptors in exercise-induced cardioprotection, rats were exercised according to the standard protocol; however, just before exercise on days 4 and 5, rats were injected subcutaneously with 10 mg/kg of the opioid receptor antagonist naltrexone. Similar injections were performed in the sham exercise control group. Naltrexone had no significant effect on baseline myocardial ischemic tolerance in controls (infarct size 43 +/- 4%). In contrast, naltrexone treatment completely blocked the cardioprotective effect of exercise (infarct size 40 +/- 5%). Exercise was also associated with an early increase in myocardial mRNA levels for several opioid system genes and with sustained changes in a number of genes that regulate inflammation and apoptosis. These findings demonstrate that the acute cardioprotective effects of exercise are mediated, at least in part, through opioid receptor-dependent mechanisms that may include changes in gene expression.