Distribution of Lower Extremity Deep Vein Thrombosis and Implications for Limited Compression Ultrasound Examinations.

BACKGROUND: Limited compression bedside ultrasonography (LCUS) including two-point, three-point, and extended compression examinations have become increasingly popular among emergency physicians to assess for lower extremity deep venous thrombosis (DVT). OBJECTIVE: Our objective in this study was to determine the prevalence and distribution of lower extremity DVT in sites identified by complete duplex ultrasonography (CDUS) that may potentially be missed using limited compression ultrasonography techniques. METHODS: This was a retrospective, multicenter study conducted at 12 hospitals within the Northwell Health system over a span of 4 years. Study participants (emergency department patients) underwent CDUS to assess for possible DVT. Images were reviewed and interpreted by radiologists and vascular surgeons at each of the participating institutions. RESULTS: A total of 42,487 CDUS examinations were performed, of which 3383 were positive for DVT. DVTs were deemed to be acute in 2664 (79%) and chronic in the remaining 21% on the basis of comparison with previous studies and appearance of the vein. Of the acute DVTs, 136 (5.1%) were confined to the common femoral vein, 116 (4.4%) to the femoral vein, 8 (0.3%) to deep femoral vein, 213 (8.0%) to popliteal vein, and 934 (35.1) to calf veins alone. CONCLUSIONS: In our study, a significant number of DVTs were identified in sites that may have been potentially missed on LCUS examinations, thereby supporting the use of complete duplex ultrasonography when available.

Does Specialty Training and Practice Setting Affect Adherence to the Pediatric Emergency Care Applied Research Network Criteria for Pediatric Head Trauma?

OBJECTIVE: The goal was to determine the effects of specialty training and practice settings on the adherence to the Pediatric Emergency Care Applied Research Network (PECARN) criteria. METHODS: A retrospective study was conducted on a 2-campus hospital. Chart documentation was used to determine adherence to PECARN criteria. Inclusion criteria were any traumatic head injury within 24 hours in patients younger than 18 years over a 1-year period. Specialty training was subdivided into 3 groups: pediatric emergency medicine, emergency medicine (EM), and general pediatrics. The 2 hospital campuses are distinctly different practice settings, one being an academic practice setting, which is also a trauma center that has a dedicated pediatric emergency department, staffed by pediatric emergency medicine, EM, and general pediatrics physicians, and the second campus is a community practice and is staffed solely by EM physicians. Statistical analysis was performed using χ and Cochran-Mantel-Haenszel tests. All analyses were 2-sided, and P < 0.05 was considered statistically significant. RESULTS: A total of 709 pediatric patients with traumatic head injuries were analyzed. Overall adherence to PECARN criteria was 93%. No statistical difference was found between different specialty training on the academic campus. In addition, the rate of adherence among EM physicians at the academic and community settings was 94.8% versus 86.5%, respectively (P = 0.004). CONCLUSIONS: Practice setting had an effect on adherence to PECARN criteria in pediatric patients with acute traumatic head injury. The same determination on adherence was not demonstrated among physicians with different specialty trainings.

Femoral nerve blocks versus standard pain control for hip fractures: a retrospective comparative analysis.

OBJECTIVE: Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control that reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures. METHODS: This retrospective study included adult patients presenting to the emergency department with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period was randomly selected to represent the control group. The primary outcome was preoperative opioid requirement, assessed by morphine milligram equivalents (MMEs). RESULTS: During the study period, 90 patients were included in each group. Mean preoperative MME was 10.3 (95% confidence interval [CI], 7.4-13.2 MME) for the intervention group and 14.0 (95% CI, 10.2-17.8 MME) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from emergency department triage to hospital discharge (7.2 days; 95% CI, 6.2-8.0 days) than patients who received standard care (8.6 days; 95% CI, 7.210.0 days). However, this difference was not statistically significant (P=0.09). CONCLUSION: Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

Association of Cryoprecipitate Use With Survival After Major Trauma in Children Receiving Massive Transfusion.

Importance: Although most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear. Objective: To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. Design, Setting, and Participants: This retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020. Exposures: Cryoprecipitate use within the first 4 hours of emergency department arrival. Main Outcomes and Measures: In-hospital 24-hour and 7-day mortality. Results: Of the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, -6.9%; 95% CI, -10.6% to -3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, -9.2%; 95% CI, -15.4% to -3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, -7.7%; 95% CI, -15.0% to -0.5%). Conclusions and Relevance: In this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.