Targeted Temperature Management for Traumatic Asphyxia: A Case Report.

Traumatic asphyxia (TA) is a rare condition due to severe crush injury to the upper abdomen or chest region. Elevated intrathoracic pressure causes impaired venous return, which damages the small vessels. Consciousness is reportedly lost in many TA cases. In the most severe cases, hypoxic encephalopathy occurs. Since TA patients usually have other traumatic complications such as thoracic or abdominal injury, the mortality rate of this syndrome is quite variable. Hypothermia is a risk factor for mortality in trauma patients, and targeted temperature management (TTM) is rarely performed for trauma cases. There are scattered articles reporting the usefulness of TTM in severe traumatic brain injury. To our best knowledge, there have been no reports of TTM in TA cases. We herein report a TA case with decorticate rigidity having a good neurological outcome after TTM.

Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians.

The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation. The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty. Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma.

OBJECTIVE: Previous cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14-15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule. METHODS: We conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning. RESULTS: 1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively. CONCLUSIONS: Our initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.

Effect of Administration of Ramelteon, a Melatonin Receptor Agonist, on the Duration of Stay in the ICU: A Single-Center Randomized Placebo-Controlled Trial.

OBJECTIVES: Occurrence of delirium in the ICU is associated with a longer stay in the ICU. To examine whether the use of ramelteon, a melatonin agonist, can prevent delirium and shorten the duration of ICU stay of critically ill patients. DESIGN: A single-center, triple-blinded, randomized placebo-controlled trial. SETTING: ICU of an academic hospital. PATIENTS: Eligible patients were ICU patients who could take medicines orally or through a nasogastric tube during the first 48 hours of admission. INTERVENTIONS: The intervention group received ramelteon (8 mg/d), and the control group received placebo (1 g/d of lactose powder) at 20:00 hours every day until discharge from the ICU. MEASUREMENTS AND MAIN RESULTS: A total of 88 subjects were randomized to the ramelteon group (45 subjects) or the placebo group (43 subjects). As the primary endpoint, there was a trend toward decrease in the duration of ICU stay (4.56 d) in the ramelteon group compared with the placebo group (5.86 d) (p = 0.082 and p = 0.028 before and after adjustments). As the secondary endpoints, statistically significant decreases in the occurrence rate (24.4% vs 46.5%; p = 0.044) and duration (0.78 vs 1.40 d; p = 0.048) of delirium were observed in the ramelteon group. The nonintubated patients of the ramelteon group showed statistically significantly fewer awakenings per night and a higher proportion of nights without awakenings. CONCLUSIONS: Ramelteon tended to decrease the duration of ICU stay as well as decreased the occurrence rate and duration of delirium statistically significantly.

A novel scoring system for predicting the neurologic prognosis prior to the initiation of induced hypothermia in cases of post-cardiac arrest syndrome: the CAST score.

BACKGROUND: The aim of this study was to develop a scoring system for identifying the post-cardiac arrest syndrome (PCAS) patients with a good potential for recovery prior to the initiation of induced therapeutic hypothermia. METHODS: A multi-center, retrospective, observational study was performed. Data of a total of 151 consecutive adults who underwent induced hypothermia after cardiac arrest (77 learning cases from two hospitals and 74 validation cases from two other hospitals) were analyzed. RESULTS: In the learning set, 8 factors (initial rhythm, witnessed status and time until return of spontaneous circulation, pH, serum lactate, motor score according to the Glasgow Coma Scale (GCS), gray matter attenuation to white matter attenuation ratio (GWR), serum albumin, and hemoglobin) were found to be strongly correlated with the neurological outcomes. A tentative scoring system was created from the learning data using these factors, and the predictive accuracy (sensitivity and specificity) was evaluated in terms of both internal validation (0.85 and 0.84) and external validation (cutoff 50%: 0.95 and 0.90, 30%: 0.87 and 0.98, 15%: 0.67 and 1.00). Finally, using all the data, we established a post-Cardiac Arrest Syndrome for induced Therapeutic hypothermia (CAST) score to predict the neurologic prognosis prior to initiation of induced hypothermia. CONCLUSIONS: The CAST score was developed to predict the neurological outcomes of PCAS patients treated by induced hypothermia. The likelihood of good recovery at 30 days was extremely low in PCAS patients with a CAST score of ≤15%. Prospective validation of the score is needed in the future.