Intracranial bleeds after minor and minimal head injury in patients on warfarin.

BACKGROUND: There is little evidence to guide physicians on management of patients who sustain head injuries while on warfarin. OBJECTIVES: Our objective was to determine the rate of intracranial bleeding in anticoagulated patients with minor and minimal head injuries and the association with clinical features and international normalized ratio (INR). METHODS: We conducted a historical cohort study of adult patients, taking warfarin, at two tertiary care emergency departments over 2 years with minor (Glasgow Coma Score 13-15, with loss of consciousness, amnesia, or confusion) or minimal (Glasgow Coma Score 15 without loss of consciousness, amnesia, or confusion) head injuries. Patients with penetrating injuries, INR < 1.5, or a new focal neurological deficit were excluded. Our outcome, intracranial bleeding, was determined by the radiologist's final computed tomography (CT) report for imaging performed within 2 weeks. RESULTS: There were 176 patients enrolled, of which 157 (89.2%) had CT and 28 (15.9%) had intracranial bleeding. Comparing patients with and without intracranial bleeding found no significant differences in INR, and loss of consciousness was associated with higher rate of intracranial bleeding. The rate of intracranial bleeding in the minor and minimal head injury groups was 21.9% and 4.8%, respectively. CONCLUSIONS: The rate of intracranial bleeding in patients on warfarin is considerable. Loss of consciousness is associated with high rates of intracranial bleeding. This study supports a low threshold for ordering CT scans for anticoagulated patients with head injuries.

Effect of waiting time estimates on patients satisfaction in the emergency department in a tertiary care center.

OBJECTIVES: To examine the influence of emergency department (ED) waiting time estimate provision on the satisfaction of patients.  Methods: This was a randomized controlled trial at King Abdulaziz Medical City, Riyadh, Saudi Arabia between September 2017 and May 2018. It included 18 to 70 years old Arabic-speaking acute care patients. After being divided into 2 groups, the intervention group alone was provided waiting time estimates. Both groups answered 2 questionnaires evaluating their satisfaction and illness perception before and after seeing a doctor. Results: One-hundred patients were included. No significant difference found in waiting time satisfaction scores between groups (intervention (5.92/10±3.13), control (5.45/10±3.38), p=0.476). Demographics and illness perception had an insignificant impact on satisfaction. Waiting time estimate was preferred by most participants (70%). Conclusion: Providing waiting time estimation did not affect satisfaction but was preferred to have in the ED by most.

Use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia.

OBJECTIVES: To determine the ultrasound guidance for central venous catheter (USG-CVC) placement rate of emergency physicians (EPs) in Kingdom of Saudi Arabia. METHODS: A cross-sectional survey study regarding the respondents' demographic profiles, formal and informal training in USG-CVC placement, experiences, and attitudes towards the procedure was emailed to all EPs registered with the Saudi Commission for Health Specialties (SCFHS) between October and December 2018. RESULTS: In total, 234/350 SCFHS-registered EPs completed the survey; the response rate was 66.9%. Most respondents (70.5%) were board-certified in emergency medicine (EM). Ninety percent indicated that US device for CVC placement assistance was available. Most EPs (78.2%) had performed USG-CVC placement; the US usage rate correlated significantly with recent graduation from residency (p=0.048). In total, 83.3% received formal training during residency. Of the 234 respondents, 53.8% felt extremely comfortable with CVC placement with USG and 19.7% without USG (p less than 0.01). Nevertheless, most respondents desired further USG-CVC training. CONCLUSION: Despite existing evidence and a consensus on its superiority over the landmark technique, USG-CVC placement has not been adopted by a small proportion of EPs into clinical practice. Formal training, education, and institutional provision of permanent onsite US machines may address any barriers.

Developing an emergency medicine handoff tool: an electronic Delphi approach.

BACKGROUND: Handoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation. METHODS: An electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements. RESULTS: Twenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach's alpha 0.93). CONCLUSIONS: This study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature.

BACKGROUND: In patients presenting with skin and soft tissue infections (SSTI), the use of ultrasound may lead to a more accurate distinction between cellulitis and abscess compared with clinical assessment alone. OBJECTIVES: This systematic review aims to determine the diagnostic accuracy of ultrasound for detecting skin abscesses. In addition, it aims to assess the impact of using ultrasound on management decisions in patients with SSTI. METHODS: We searched relevant electronic databases for primary studies including MEDLINE, EMBASE, and CINAHL. We searched conference proceedings, checked references of retrieved articles, and contacted field experts. Two reviewers assessed the quality of each full-text publication using a modified QUADAS-2 tool. RESULTS: Five studies (n=710) fulfilled our inclusion criteria. Four studies compared the diagnostic accuracy of ultrasound with clinical examination alone (n=584). Most studies reported an improvement in diagnostic accuracy. The sensitivity of ultrasound ranged from 89 to 98% and the specificity ranged from 64 to 88%. However, the sensitivity of clinical assessment ranged from 75 to 90% and the specificity ranged from 55 to 83%; most of these results did not reach statistical significance. Sensitivity was further improved in cases of indeterminate clinical assessment. Two studies (n=176) examined the impact of ultrasound on management decisions. Use of ultrasound has led to significant and appropriate changes in management decisions in 16 to 39% of patients. CONCLUSION: The use of ultrasound could potentially improve diagnostic accuracy and lead to improved management decisions in patients with SSTI, especially in cases of indeterminate clinical assessment. Most of our findings did not achieve statistical significance. Further research is required to confirm these findings.

Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis.

BACKGROUND: A pneumothorax is a potentially life-threatening condition. Although CT scan is the reference standard for diagnosis, chest radiographs are commonly used to rule out the diagnosis. We compared the test characteristics of ultrasonography and supine chest radiography in adult patients clinically suspected of having a pneumothorax, using CT scan or release of air on chest tube placement as reference standard. METHODS: We searched for English literature in MEDLINE and EMBASE and performed hand searches. Two independent investigators used standardized forms to review articles for inclusion, quality (QUADAS tool), and data extraction. We calculated κ agreement for study selection and evaluated clinical and quality homogeneity before meta-analysis. RESULTS: We reviewed 570 articles and selected 21 for full review (κ, 0.89); eight articles (total of 1,048 patients) met all inclusion criteria (κ, 0.81). All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Chest radiography data were available for 864 of 1,048 patients evaluated with ultrasonography. Ultrasonography was 90.9% sensitive (95% CI, 86.5-93.9) and 98.2% specific (95% CI, 97.0-99.0) for the detection of pneumothorax. Chest radiography was 50.2% sensitive (95% CI, 43.5-57.0) and 99.4% specific (95% CI, 98.3-99.8). CONCLUSIONS: Performance of ultrasonography for the detection of pneumothorax is excellent and is superior to supine chest radiography. Considering the rapid access to bedside ultrasonography and the excellent performance of this simple test, this study supports the routine use of ultrasonography for the detection of pneumothorax.