The Dangers of Spear Tackling: A Case Report of a NEXUS-negative High School Football Player.

BACKGROUND: Although "spear tackling" is known to be a risk factor for cervical spine injury due to axial loading of the neck, and although this technique was officially banned from American football in 1976, football-associated cervical spine injuries continue to be reported. This case highlights the importance of recognizing high-risk mechanisms for cervical spine injury, and specifically the danger of spear tackling among football players at all levels. CASE REPORT: A 16-year-old male high school football player presented to the pediatric emergency department for a neck injury sustained after spear tackling during a football game. He had no neurologic symptoms and met the NEXUS criteria for omitting x-ray evaluation. However, the description of spear tackling as the mechanism of injury led to the ordering of cervical radiographs, which revealed a C5 fracture. The patient was ultimately taken to the operating room for internal fixation, with a final surgical diagnosis of a C5 teardrop fracture. On outpatient follow-up at 1 year, the patient has had no neurologic sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case serves as a reminder that all evaluations of trauma patients should begin with an attempt to determine, as precisely as possible, the mechanism that was in play at the time of injury. The reassurance provided by a normal physical examination may be misleading. Spear tackling is not an uncommonly encountered cause of injury in American football, despite the practice being prohibited since a rule change in 1976. Continued education and increased awareness of the association of axial load injury with spear tackling may make it possible to avoid missing a potentially devastating cervical spine injury.

A descriptive study of myoclonus associated with etomidate procedural sedation in the ED.

BACKGROUND: Myoclonus is a well-recognized side effect of etomidate when given in induction doses for rapid sequence intubation. Most of the data reported on myoclonus with emergency department (ED) sedation doses are reported as a secondary finding. STUDY OBJECTIVES: Our objective was to prospectively quantify the incidence and duration of myoclonus associated with the administration of etomidate in the lower doses given for procedural sedation in the ED. METHODS: This was a prospective descriptive study performed between September 2008 and September 2010 at an urban teaching hospital ED with approximately 50000 patient visits per year. Procedural sedation was performed at the discretion of the treating emergency physician, and adult patients receiving etomidate were eligible for enrollment. The occurrence and duration of myoclonus were observed and recorded. Any interference of myoclonus with the ability to complete the procedure was recorded, and adverse effects were identified. RESULTS: Thirty-four eligible subjects were enrolled, and 36 separate sedation procedures were performed. The mean initial etomidate dose was 0.13 mg/kg (range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range, 0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93 seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%) of 36 attempted procedures, and no procedure was unsuccessful because of myoclonus. CONCLUSION: Myoclonus associated with sedation doses of etomidate was common but rarely interfered with the completion of a procedure.

Resolution of Hydronephrosis and Pain to Predict Stone Passage for Patients With Acute Renal Colic.

OBJECTIVE: To study patients who presented to the Emergency Department with acute renal colic to determine if resolution of hydronephrosis and pain accurately predicts stone passage on follow-up CT. MATERIALS AND METHODS: This is a secondary analysis of a multicenter prospective randomized clinical trial of patients diagnosed by computed tomography (CT) scan with a symptomatic ureteral stone < 9 mm in diameter. Participants were followed after randomization to evaluate for analgesic use and to assess stone passage and hydronephrosis on a repeat CT scan obtained at 29-36 days. RESULTS: Four-hundred-three patients were randomized in the original study and patients were included in this analysis if they did not have surgery for stone removal and had a CT scan and information on pain medication at follow-up (N = 220). Hydronephrosis was detected in 181 (82%) on initial CT. At follow-up CT, 43 (20%) participants had a persistent ureteral stone. Of these patients, 36 (84%) had no pain, 26 (60%) did not have hydronephrosis, and 23 (53%) had neither pain nor hydronephrosis. Resolution of hydronephrosis was associated with stone passage (RR 4.6, 95% CI 1.9, 11.0), while resolution of pain was not (RR 1.1, 95% CI 0.9, 1.4). CONCLUSION: In patients with urinary stone disease, stone passage is associated with resolution of hydronephrosis but not resolution of pain. In patients with persistent ureteral stones, neither pain nor hydronephrosis are consistently present. These findings have important implications on follow-up imaging of patients with urinary stone disease.

Analgesic and Opioid Use for Patients Discharged from the Emergency Department with Ureteral Stones.

Objective: The aim of this study was to describe and characterize the analgesic and opioid use for patients discharged from the emergency department (ED) with renal colic due to ureteral stone. Methods: This is a secondary analysis of a multicenter prospective trial of ED patients diagnosed by CT scan as having a symptomatic ureteral stone <9 mm in diameter. Participants were contacted after randomization on days 2, 7, 15, 20, and 29 and reported opioid and nonopioid analgesic use and stone passage. CT scan was repeated on day 29 to 36 to confirm passage. Results: Of 403 participants, 314 (77.9%) took an analgesic after discharge and 199 (49.4%) took opioids. Opioids were more commonly used by younger patients (p = 0.04) and those with a family history of stones (p = 0.003). Stone size and tamsulosin use were not associated with analgesic utilization. Shorter time to passage and more distal stone location were associated with less analgesic and opioid use. For those who did not expel a stone, 55.0% took opioids at any time, and for those who did expel a stone, 31.9% took opioids before the stone was expelled and 15.7% took opioids at any time after the stone was expelled. Conclusions: Factors associated with increased use of analgesics in patients discharged from the ED include a longer time to stone passage, no spontaneous passage, and proximal position of the stone in the ureter. Some patients continued to use analgesics after the stone had passed, but most stopped using analgesics by day 29. The study has been registered at https://clinicaltrials.gov (NCT00382265).

Postpartum preeclampsia occurring after resolution of antepartum preeclampsia.

Preeclampsia is a syndrome characterized by hypertension, proteinuria and edema in a pregnant female after 20 weeks of gestation, including occurring in the postpartum period. Delivery of the infant is usually considered the definitive treatment for preeclampsia. Preeclampsia in a prior pregnancy is associated with an increased risk of recurrence in a subsequent pregnancy. However, it is unusual for preeclampsia to resolve with delivery of the infant and then recur in the same pregnancy in the postpartum period. We present here a case report of a woman who had antepartum preeclampsia treated with delivery. She then had a recurrence of the classic signs of preeclampsia in the postpartum period. Ultimately she was admitted and treated with magnesium with a final diagnosis of recurrent preeclampsia.

Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center.

OBJECTIVES: Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up. METHODS: We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria. RESULTS: Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases. CONCLUSIONS: Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings.

Clinically suspected coagulopathy in blunt head trauma.

Patients with moderate to severe head injury and abnormal coagulation studies have a significantly higher risk of brain injury. The objective of this study was to determine the association of clinical suspicion of coagulopathy and intracranial injury (ICI) among patients sustaining blunt head trauma, including minor injuries. As part of the NEXUS II blunt head injury study, enrolled patients were prospectively evaluated for ICI and suspicion of coagulopathy. We examined the relationship between suspicion of coagulopathy and the presence of any clinically significant or "therapeutically inconsequential" ICI based on head computed tomography (CT) scan results. The NEXUS II study enrolled 13,728 patients, including 493 with suspicion of coagulopathy. Significant ICI was present in 46 (9.3%; 95% confidence interval [CI] 6.9-12.2) patients with suspected coagulopathy, and in 460 of 9863 (4.7%; 95% CI 4.3-5.1) patients without such suspicion. "Therapeutically inconsequential" findings were found on head CT scan in 74 patients, and 7 of these had suspected coagulopathy. Interventions including intubation, intracranial pressure monitoring, or craniotomy were performed in 5 of these 7 (71%; 95% CI 29-96) individuals, compared with only 3 of 67 (4%; 95% CI 1-12) patients without suspicion of coagulopathy. Initial clinical suspicion of coagulopathy, independent of laboratory confirmation, is associated with a greater prevalence of significant ICI injury after blunt head trauma; it also substantially increases the risk of morbidity despite the presence of an apparent "therapeutically inconsequential" injury. CT scanning of the head should be performed initially based on clinical suspicion of coagulopathy.

Accuracy of Patient Reported Stone Passage for Patients With Acute Renal Colic Treated in the Emergency Department.

OBJECTIVE: To study patients who initially presented to the Emergency Department with acute renal colic to determine if patient-reported stone passage detects stone expulsion as accurately as follow-up computed tomography (CT) scan. METHODS: This is a secondary analysis of a multi-center prospective trial of patients diagnosed by a CT scan with a symptomatic ureteral stone <9 mm in diameter. Patient-reported stone passage, defined as capture or visualization of the stone, was compared to CT scan-confirmed passage performed 29-36 days after initial presentation. RESULTS: Four-hundred-three patients were randomized in the original study and 21 were excluded from this analysis because they were lost to follow-up or received ureteroscopic surgery. Of the 382 remaining evaluable patients, 237 (62.0%) underwent a follow-up CT scan. The mean (standard deviation) diameter of the symptomatic kidney stone was 3.8 mm (1.4). In those who reported stone passage, 93.8% (91/97) demonstrated passage of the symptomatic ureteral stone on follow-up CT. Of patients who did not report stone passage, 72.1% (101/140) demonstrated passage of their stone on follow-up CT. CONCLUSIONS: For patients who report capture or visualization of a ureteral stone, a follow-up CT scan may not be needed to verify stone passage. For patients who do not capture their stone or visualize stone passage, imaging should be considered to confirm passage.

The prevalence and factors associated with QTc prolongation among emergency department patients.

STUDY OBJECTIVE: Previous studies have suggested that QTc prolongation may lead to significant morbidity and mortality. The prevalence of QTc prolongation among emergency department (ED) patients is unknown. The purpose of this study is to determine the prevalence of QTc prolongation among ED patients. METHODS: This was a retrospective review of ED and inpatient data for all patients with an ECG conducted for any reason at a tertiary care university ED during a 3-month period. QTc prolongation was defined as computer-generated QTc intervals greater than or equal to 450 ms for men and greater than or equal to 460 ms for women. RESULTS: Of the 1,558 eligible cases, 544 patients had QTc prolongation (35%; 95% confidence interval [CI] 32% to 37%). The prevalence of QTc intervals greater than or equal to 500 ms was 8% (120/1,558; 95% CI 6% to 9%). The most common comorbidities were structural heart disease, renal failure, and stroke. Forty-four percent (239/544; 95% CI 40% to 48%) of patients with any degree of QTc prolongation were discharged from the ED. Furthermore, 23% (28/120; 95% CI 16% to 32%) of patients with QTc intervals greater than or equal to 500 ms were discharged from the ED, including 16 patients with QTc intervals greater than or equal to 500 ms and QRS durations less than 120 ms (16/60; 27%; 95% CI 16% to 40%). Five percent of the patients with QTc prolongation died in the ED or during hospitalization (27/544; 95% CI 3% to 7%); none had QTc prolongation or torsades de pointes listed as a cause of death. CONCLUSION: QTc prolongation occurred frequently among ED patients who had an ECG study for any reason. Nearly half of all patients with QTc prolongation were discharged from the ED.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? or Do as We Do?

BACKGROUND: Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions. METHODS: Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV. RESULTS: There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning. CONCLUSION: Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial.

Importance: Urinary stone disease is a common presentation in the emergency department, and α-adrenergic receptor blockers, such as tamsulosin, are commonly used to facilitate stone passage. Objective: To determine if tamsulosin promotes the passage of urinary stones within 28 days among emergency department patients. Design, Setting, and Participants: We conducted a double-blind, placebo-controlled clinical trial from 2008 to 2009 (first phase) and then from 2012 to 2016 (second phase). Participants were followed for 90 days. The first phase was conducted at a single US emergency department; the second phase was conducted at 6 US emergency departments. Adult patients were eligible to participate if they presented with a symptomatic urinary stone in the ureter less than 9 mm in diameter, as demonstrated on computed tomography. Interventions: Participants were randomized to treatment with either tamsulosin, 0.4 mg, or matching placebo daily for 28 days. Main Outcomes and Measures: The primary outcome was stone passage based on visualization or capture by the study participant by day 28. Secondary outcomes included crossover to open-label tamsulosin, time to stone passage, return to work, use of analgesic medication, hospitalization, surgical intervention, and repeated emergency department visit for urinary stones. Results: The mean age of 512 participants randomized to tamsulosin or placebo was 40.6 years (range, 18-74 years), 139 (27.1%) were female, and 110 (22.8%) were nonwhite. The mean (SD) diameter of the urinary stones was 3.8 (1.4) mm. Four hundred ninety-seven patients were evaluated for the primary outcome. Stone passage rates were 50% in the tamsulosin group and 47% in the placebo group (relative risk, 1.05; 95.8% CI, 0.87-1.27; P = .60), a nonsignificant difference. None of the secondary outcomes were significantly different. All analyses were performed according to the intention-to-treat principle, although patients lost to follow-up before stone passage were excluded from the analysis of final outcome. Conclusions and Relevance: Tamsulosin did not significantly increase the stone passage rate compared with placebo. Our findings do not support the use of tamsulosin for symptomatic urinary stones smaller than 9 mm. Guidelines for medical expulsive therapy for urinary stones may need to be revised. Trial Registration: ClinicalTrials.gov Identifier: NCT00382265.

Case series: diverticulitis in the young.

Diverticulitis has long been regarded as a disease of the elderly, but its incidence has been increasing in those under age 40. Younger patients with diverticulitis are more likely to be male and obese. They often have atypical presentations, and 25% may have right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed, resulting in unnecessary surgery. An abdominal CT scan is the modality of choice for diagnosis, but the most important diagnostic step is simply to include diverticulitis on the differential diagnosis of a young person with lower abdominal pain.

Design and challenges of a randomized clinical trial of medical expulsive therapy (tamsulosin) for urolithiasis in the emergency department.

Urolithiasis or urinary stone disease has been estimated to affect about 1 in 11 Americans. Patients with urinary stone disease commonly present to the emergency department for management of their acute pain. In addition to providing analgesia, administration of drug (medical expulsive therapy) is often prescribed to assist passage of the urinary stone. In this methodology paper, we describe the design of a prospective, multi-center, randomized, double-blind placebo controlled clinical trial of the alpha-adrenergic blocker, tamsulosin, to evaluate its effectiveness as medical expulsive therapy. In addition, we describe the unique challenges of conducting a trial of this type within the setting of the emergency department.

Postpartum focal neurologic deficits: posterior leukoencephalopathy syndrome.

The postpartum patient who presents with focal neurologic deficits presents a wide range of diagnostic possibilities. We report the case of a previously healthy woman who presented 7 days postpartum with a focal deficit and who was ultimately diagnosed with eclampsia and posterior leukoencephalopathy syndrome (PLES). The hallmark of this entity is reversible parieto-occipital white matter edema as seen on magnetic resonance imaging (MRI). Advanced MRI techniques, such as echo-planar diffusion-weighted images and apparent diffusion coefficient maps, suggest cerebral artery dilatation as the underlying mechanism. Laboratory findings and computed tomography (CT) scans are typically unremarkable. PLES has a favorable prognosis if treated promptly and appropriately.