South Texas orbital fracture protocol for emergency department evaluation of orbital fractures.

PURPOSE: Facial trauma and orbital fractures are common reasons for ophthalmology consultation in the emergency department (ED). The purpose of this study is to assess intervention rates and evaluate the acuity of ophthalmology consultation for orbital fractures in the ED. BASIC PROCEDURES: A retrospective chart review of orbital fractures was conducted over a 23-month period. 379 cases of orbital fractures were identified in a single-center study. All patients that received an ophthalmology consultation in the ED were included. Demographics, mechanism and location of orbital fracture, ophthalmic complications, and surgical and non-surgical ophthalmic interventions were recorded. The primary study outcome was the rate of ophthalmic consultation and intervention with and without retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP). RESULTS: Immediate ophthalmic intervention was performed in 18.7% of patients. Statistically significant subjective, radiographic, and physical exam features correlating with ophthalmic intervention were identified and included globe rupture, concern for entrapment, orbital roof fractures, and retrobulbar hematoma. Retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP) would have resulted in 186 of 379 patients requiring ophthalmology consultation, thus reducing consultation rate by 51% with an improved rate of intervention from 18.7% to 37.6%. CONCLUSIONS: Orbital fractures can be associated with severe ocular complications. Most cases, however, do not require emergent evaluation by an ophthalmologist. We propose the South Texas Orbital Fracture Protocol (STOP) for proper assessment and triaging of orbital fractures in the ED. While this clinical decision-making tool requires validation, it may offer improved healthcare efficiency, reduced costs, fewer unnecessary inter-facility transfers, and less burnout for ophthalmology residents.

Postconcussion Academic Support in Children Who Attend a Primary Care Provider Follow-up Visit after Presenting to the Emergency Department.

OBJECTIVE: To examine whether a primary care provider (PCP) follow-up visit after emergency department evaluation of concussion improved the children's likelihood of receiving academic support. STUDY DESIGN: This was a prospective cohort study. Concussed children, aged 8-18 years, presenting to a regional pediatric trauma center emergency department (n = 160) were contacted 7 and 30 days after injury to gather data on PCP follow-up, symptoms, quality of life, and receipt of academic support instituted after and because of the concussion. Bivariate comparisons of demographics, concussion characteristics, quality of life, and symptoms were made between children who did and did not receive support using independent samples t tests, Wilcoxon rank sum tests, or χ2 tests. ORs and 95% CIs were calculated using multivariable logistic regression with backwards elimination to test the association between attending an outpatient follow-up visit and the receipt of academic support for variables where P < .2 in bivariate comparisons. RESULTS: Overall, 51.3% (n = 82) received academic support; of these, 84.2% attended a follow-up visit compared with 71.8% of 78 children who attended a follow-up visit but did not receive support (P = .06). Children who received support were more likely to have commercial insurance; experience a sports-related injury mechanism; have parents whose primary language was English; suffer from learning disabilities and migraines; and be non-Hispanic (P < .05). There was no association between attending a follow-up visit and receipt of academic support (adjusted OR 1.83; 95% CI 0.75-4.45). CONCLUSIONS: Although the majority of children received academic support postconcussion, accommodations were associated with several demographic, medical history, and injury characteristics, but not attending a PCP follow-up visit.

The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage.

Background: American College of Emergency Physicians (ACEP) [1] recommends that patients presenting with acute non-traumatic headache concerning for subarachnoid hemorrhage (SAH) undergo lumbar puncture (LP) when non-contrast head computed tomography (CT) is negative. The diagnostic yield of this approach is unknown. Objective: Evaluate the diagnostic yield, lengths of stay and complication rates of LPs in patients undergoing Emergency Department (ED) evaluation for aneurysmal SAH. Methods: Multi-center, retrospective, hypothesis-blinded, explicit chart review of patients undergoing ED-based lumbar puncture between 2007 and 2012. Charts of neurologically intact patients presenting with headache that had a negative head CT and underwent LP primarily to rule out SAH were reviewed. Trained data abstractors blinded to study hypothesis used standardized data forms with predefined terms for chart abstraction. We re-abstracted and assessed inter-rater agreement for 20 percent of charts with a 100 percent inter-rater agreement. Data were descriptive, using 95 percent confidence intervals. Results: 1,282 LPs were performed, and 342 patients met inclusion criteria but only 1 percent were deemed positive for SAH in the chart. No aneurysm or vascular malformation was identified in those with positive LPs for SAH. Complications were in 4 percent and xanthochromia was found in 13 percent. Total length of stay was 7.8 hours (0.95 CI; 7.5 - 8.2). No patient discharged from the ED after a negative workup for SAH was re-admitted for SAH or underwent a neurosurgical procedure during a three-month follow-up period. Conclusions: LP in our cohort of neurologically intact CT-negative ED headache patients did not identify any cases of aneurysmal SAH but was associated with serious complications, a significant false positive rate, and extended ED length of stay.

Singultus: Avoiding a hiccup in care.

Hiccups (singultus) is often a benign, common and self- limited condition. A case of profound electrolyte disturbances presenting with chief complaint of hiccups is presented in which chlorpromazine was not administered and could have been problematic had it been given. For those who present to the ED with chief complaint of hiccups, it is critical to consider a life threatening etiology as the cause of their symptom. This case presents a potential pitfall in the management of singultus.

A Case of Green Nail Syndrome Diagnosed in the Emergency Department.

Green nail syndrome (GNS) is a rare diagnosis in which a patient presents with green-yellow, green-blue, or green-brown discoloration of a finger or toenail. It occurs due to a Pseudomonas aeruginosa infection of the nail. Pseudomonas aeruginosa produces pigments that can infuse into the underside of the nail plate, creating a color change. Here, we present the case of a 34-year-old female with a green-brown area of discoloration of her right middle finger in which the diagnosis of GNS was made. The patient used acrylic nails, which is a known risk factor. The characteristic clinical context and physical exam findings of green-yellow, green-blue, or green-brown nail discoloration are said to be sufficient to make a working diagnosis of GNS. The differential diagnosis of GNS includes a subungual hematoma, a subungual melanoma, and exogenous yellow pigment exposure. The history, physical examination, and response to treatment will help to clarify the differential. Ciprofloxacin is a commonly used empiric treatment. Laboratory testing of a nail clipping can be used in cases that do not respond to treatment. Cultures of nail clippings appear to be specific, but not sensitive, to the detection of P. aeruginosa. Our patient saw an immediate improvement within a week of treatment, with complete resolution in eight weeks. This is a typical timeframe. Knowledge of the syndrome can be helpful to reduce patient anxiety and guide effective therapy.

Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State.

OBJECTIVE Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection. METHODS A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score-adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level. RESULTS Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41-0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40-0.96) and a propensity score-adjusted model (OR 0.64, 95% CI 0.41-0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed. CONCLUSIONS Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.