Exogenous Peptide Injection Causing Medical Thigh Compartment Syndrome.

BACKGROUND: Acute compartment syndrome can be caused by any condition that increases the pressure of an intracompartmental muscular space, resulting in ischemia, which is a limb-threatening emergency. This case report is the first known documented example of an exogenously injected peptide causing compartment syndrome. The use of natural supplements and holistic therapies is on the rise, specifically, peptide injections. It is important to obtain the history of use and routes of administration of these substances. CASE REPORT: We present a case of a 43-year-old man who presented to the Emergency Department with worsening thigh pain. The patient had injected a "peptide cocktail" into his thigh 3 days prior. Physical examination revealed trace pitting edema of the left leg with moderate muscle spasm and tenderness of the medial aspect of the distal thigh with associated numbness along the medial aspect of the knee. Point-of-care ultrasound detected intramuscular edema and free fluid in the leg. He was found to have acute compartment syndrome of the thigh secondary to the peptide cocktail injection, causing a large hematoma posterior to the adductor magnus. The patient required fasciotomy and hematoma evacuation. He ultimately left against medical advice during his hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In an age when many patients look for supplements to aid with weight loss and muscle growth, it is essential to be aware of peptide injection therapies and the potential complication of compartment syndrome.

The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.

BACKGROUND: Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care. METHODS: A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated. RESULTS: A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care. CONCLUSION: Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Repeat Fall Risk in Geriatric Patients After Fall-Induced Head Trauma.

Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma.

BACKGROUND: Although clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. OBJECTIVE: This study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. METHODS: This prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. RESULTS: We enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67-13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67-13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15-12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24-1.99), alcohol use (OR 1.62; 95% CI 1.25-2.09), antiplatelet use (OR 1.84; 95% CI 1.46-2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54-4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. CONCLUSIONS: Although ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness.

Objective: Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients. Methods: This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention. Results: Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation. Conclusion: Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Comparing rates of skull fractures in female versus male geriatric patients who sustain head injuries.

BACKGROUND: Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. This study aims to evaluate the role of sex in the risk of skull fracture in patients over the age of 65. METHODS: A prospective cohort study was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents. Over a year-long period, consecutive patients aged 65 years and older who presented with blunt head injury were included. Patients who did not receive head CT imaging were excluded. The primary outcome was rate of skull fracture due to the acute trauma, compared by sex. Additional factors examined included patient race/ethnicity and mechanism of injury. RESULTS: Among 5402 patients enrolled, 3010 (56%) were female and 2392 (44%) were male. 4612 (85%) of the head injuries sustained were due to falls, and 4536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2-2.1, p = 0.002). This trend was also seen across race/ethnicity and mechanism of injury. CONCLUSIONS: Older males were found to have a higher rate of skull fractures compared to females after sustaining blunt head trauma, mostly due to falls.

A Simulation-based PPE orientation training curriculum for novice physicians.

Background: Personal protective equipment (PPE) is effective in preventing coronavirus disease (COVID-19) infection. Resident knowledge of proper use and effective training methods is unknown. We hypothesise that contamination decreases and knowledge increases after a formalised PPE educational session. Methods: Participants included first year interns during their residency orientation in June 2020. Before training, participants took a knowledge test, donned PPE, performed a simulated resuscitation, and doffed. A standardised simulation-based PPE training of the donning and doffing protocol was conducted, and the process repeated. Topical non-toxic highlighter tracing fluid was applied to manikins prior to each simulation. After doffing, areas of contamination, defined as discrete fluorescent areas on participants' body, was evaluated by ultraviolet light. Donning and doffing were video recorded and asynchronously rated by two emergency medicine (EM) physicians using a modified Centers for Disease Control and Prevention (CDC) protocol. The primary outcome was PPE training effectiveness defined by contamination and adherence to CDC sequence. Results: Forty-eight residents participated: 24 internal medicine, 12 general surgery, 6 EM, 3 neurology, and 3 psychiatry. Before training, 81% of residents were contaminated after doffing; 17% were contaminated after training (P<0.001). The most common contamination area was the wrist (50% pre-training vs. 10% post-training, P<0.001). Donning sequence adherence improved (52% vs. 98%, P<0.001), as did doffing (46% vs. 85%, P<0.001). Participant knowledge improved (62%-87%, P <0.001). Participant confidence (P<0.001) and preparedness (P<0.001) regarding using PPE increased with training. Conclusion: A simulation-based training improved resident knowledge and performance using PPE.

Sudden Decompensation of Patients Admitted to Non-ICU Settings Within 24 h of Emergency Department Admission.

BACKGROUND: Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics. METHODS: This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not. RESULTS: Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p = 0.023) and dyspnea (70.6% vs 29.4%, p = 0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p = 0.010) or hypertension (9.1% vs 0%, p = 0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p = 0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p = 0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found. CONCLUSIONS: Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.

Cerebellar Infarction from a Vertebral Artery Dissection after Blunt Chest Injury: A Case Report.

Introduction: Traumatic vertebral artery dissections resulting in stroke are relatively rare occurrences, especially in the absence of classic physical examination findings. Case Report: We present the case of a 30-year-old male with chest pain following a car axle falling onto his chest while trying to change a tire. He was discharged from the emergency department after having a negative workup for thoracic injury. Six hours later, the patient returned with headache and was found to have a cerebellar stroke secondary to vertebral artery dissection. After hospitalization, the patient was discharged home without any neurological deficits. Conclusion: As they are usually asymptomatic, up to 80% of patients with blunt cerebrovascular injury will have delayed or missed diagnoses. Given the increased awareness of vascular injuries and their high morbidity, physicians should maintain a high index of suspicion for this diagnosis.

Impact of COVID-19 on emergency medicine resident procedure performance.

Background: As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic. Methods: This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February. Results: A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001). Conclusions: The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.

The Treatment of COVID-19 With Monoclonal Antibody Therapy: Patient-Reported Outcomes.

Objective There have been many efforts to research and produce treatment modalities for COVID-19. Monoclonal antibodies have been one of the effective treatments since their approval by the US Food and Drug Administration (FDA) under emergency use authorization (EUA) in 2020. This study surveyed COVID-19 patients about their disease course and experience with monoclonal antibody treatment. Methods Patients who received monoclonal antibody treatment between February 12, 2021, and June 2, 2021, at a South Florida community hospital were enrolled in the study. This included patients over 18 years of age with a confirmed positive COVID-19 test result, with mild to moderate symptoms within 10 days of onset and identified as high risk for progression to severe disease. There were no exclusion criteria. After 30 days, patients were followed up via a structured telephone survey regarding subsequent emergency department (ED) visits for worsening COVID-19 symptoms, need for oxygenation, intubation, and death. Secondary outcomes were adverse effects and patient perceptions. Results Among the 119 patients who received monoclonal antibodies during the established time frame, 93 (78.1%) consented to participate in the telephone survey. Of these, 11.8% had a subsequent visit to the ED for worsening COVID-19 symptoms, 6.5% required oxygen, and 2.2% were admitted to the intensive care unit (ICU). There were no reported intubations or deaths. The vast majority (91.4%) would recommend monoclonal antibody treatment to others. Conclusion Patients who received monoclonal antibody therapy had low rates of subsequent ED visits and rarely required oxygen or ICU admission. The majority of patients would recommend treatment with monoclonal antibodies to others.

Controversial COVID-19 Cures: Hydroxychloroquine and Oleander Pediatric Ingestion Simulation Cases.

INTRODUCTION: The use of hydroxychloroquine has dramatically increased since being touted as a potential therapeutic in combating coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus. This newfound popularity increases the risk of accidental pediatric ingestion, whereby just one or two tablets causes morbidity and mortality from seizures, cardiac dysrhythmias, and cardiogenic shock. The unique management of hydroxychloroquine overdose makes it imperative for emergency medicine physicians to have familiarity with treating this condition. Similarly, ​​during the COVID-19 pandemic, there have been publicized cases touting extracts of oleander as being a potential therapeutic against the illness. Since it is commonly available and potentially lethal ingestion with a possible antidote, we developed a simulation case based on the available literature. The two cases were combined to create a pediatric toxicology curriculum for emergency medicine residents and medical students. Both of these treatments were selected as simulation cases since they were being touted by prominent national figures as potential cures for COVID-19. METHODS: Two series of simulation cases were conducted in a high-fidelity simulation lab with emergency medicine residents and medical students. The hydroxychloroquine simulation case involved the management of a four-year-old male who presented to the emergency department with nausea, vomiting, and tachycardia after ingesting hydroxychloroquine tablets. As the case unfolded, the child became increasingly unstable, eventually experiencing QT prolongation, torsades de pointes, and ventricular fibrillation arrest requiring appropriate resuscitation to achieve a return of spontaneous circulation. The oleander simulation case involved the management of a three-year-old male who presented to the emergency department with nausea, vomiting, and tachycardia after ingesting parts of an unknown plant. As that case progresses, the child becomes increasingly unstable, eventually experiencing atrial fibrillation, bradycardia, and degenerating into pulseless electrical activity and cardiac arrest requiring appropriate resuscitation to achieve the return of spontaneous circulation. Both series of simulation cases were modifiable based on trainee level and had the ability to include ancillary emergency department staff. RESULTS: Each simulation case was performed six times at our simulation center, with a total of 22 learners for the hydroxychloroquine case, and 14 for the oleander case. Through pre- and post-simulation confidence assessments, learners demonstrated increases in knowledge of toxidromes, evaluating pediatric overdoses, treating cardiac dysrhythmias, performing pediatric advanced life support, and managing post-arrest care. Learners also demonstrated improvements in recognizing the unique treatment of hydroxychloroquine and oleander toxicity, the toxic dose of both substances in a child, and the most common electrolyte anomaly seen in each toxicity. DISCUSSION: Simulation training enables learners to manage rare and complex disease processes. These cases were designed to educate trainees in recognizing and treating rare overdoses of emerging "therapeutics" that were touted early in the COVID-19 pandemic.

Time from hospital presentation to head imaging in White, Black, and Hispanic geriatric trauma patients.

BACKGROUND: Health care disparities have been shown to negatively affect non-White people sustaining traumas, leading to increased morbidity and mortality. One possible explanation could be delays in emergent medical care. This study aims to assess if a disparity between races exists amongst acutely head-injured geriatric patients, as evidenced by the time it takes from emergency department (ED) presentation to performance of head computerized tomography (CT) imaging. METHODS: A prospective cohort study was conducted from August 15, 2019 to August 14, 2020 at the two trauma centers in a south Florida county covering 1.5 million residents. Patients aged ≥ 65 years who sustained a head injury were identified daily. Patients who had a head injury >24 h prior, sustained penetrating trauma, or were transferred from another hospital were excluded. The primary outcome was time measured between ED presentation and CT head performance. Patients were grouped by race as selected from White, Black, Hispanic, and other. Comparisons were made using ANOVA analysis. RESULTS: 4878 patients were included. 90% were White. The mean times to CT head were 90.3 min for White patients, 98.1 min for Black patients, and 86.6 min for Hispanic patients. There was a significant difference comparing time to CT between the three groups (F = 2.892, p = 0.034). Comparing each group to a combined others, there were no significant differences for White vs non-White (90.3 vs 91.3, F = 0.154, p = 0.695) or Hispanic vs non-Hispanic (86.6 vs 90.5, F = 0.918, p = 0.338); however Black vs non-Black (98.1 vs 89.9, F = 4.828, p = 0.028) was significant. CONCLUSIONS: Geriatric Black patients who sustained head trauma were found to have a longer time from ED presentation to performance of head CT than their non-Black counterparts.

Ivermectin in COVID-19: The Case for a Moratorium on Prescriptions.

In treatment or prevention of COVID-19, ivermectin is not approved by the United States (US) Food and Drug Administration (FDA). Nonetheless, in the US, prescriptions of ivermectin by healthcare providers have increased > tenfold from 3589 per week pre-COVID-19 to 39,102. Ivermectin is FDA approved for animals to treat parasites and for humans to treat intestinal strongyloidiasis and onchocerciasis orally, and ectoparasites and skin conditions topically. It is not a benign drug, with reported side effects including cutaneous, gastrointestinal, and cardiovascular symptoms. The evidence to support ivermectin to treat or prevent COVID-19 includes some basic research and inconsistent clinical observations that contribute to the formulation of a hypothesis of efficacy in COVID-19. At present, data from peer-reviewed published randomized trials of sufficient size, dose, and duration to reliably test the hypothesis of the most plausible small to moderate benefits on clinically relevant endpoints are sparse. In addition to the US FDA, the US National Institutes of Health, World Health Organization, and European Medicines Agency have all advised against ivermectin for treatment or prevention of COVID-19 outside of randomized trials. For ivermectin in treatment or prevention of COVID-19, healthcare providers should reassure all patients that if sufficient evidence were to emerge, then this drug could be considered a therapeutic innovation and regulatory authorities would approve the drug. In the meanwhile, we strongly recommend a moratorium on the prescription of ivermectin for the treatment or prevention of COVID-19 except in randomized trials to provide the most reliable test of the hypothesis.

Age adjusted D-dimer cutoffs for pulmonary embolism in a geriatric population utilizing a D-dimer unit assay.

BACKGROUND: Age adjusted serum d-dimer (AADD) with clinical decision rules have been utilized to rule out pulmonary embolism (PE) in low-risk patients; however, its use in the geriatric population has been questioned and the use of d-dimer unit (DDU) assay is uncommon. OBJECTIVE: The present study aims to compare the test characteristics of the AADD (age × 5) measured in DDU with the standard cutoff (DDU < 250) and study hospital laboratory's d-dimer cutoff (DDU < 600) in geriatric patients presenting with suspected PE. METHODS: This retrospective study enrolled patients ≥65 years old with suspected PE and d-dimer performed between January 1, 2019 and December 31, 2019 who presented to the emergency department (ED). Charts were reviewed for CTA chest and ventilation perfusion imaging results for PE. Diagnostic parameters for each cutoff were calculated for the primary outcome. RESULTS: 510 patients were included, 20 with PE. There was no significant difference between the sensitivities of AADD (100%, 95% CI: 80-100), standard cutoff (100%, 95% CI: 80-100), and hospital cutoff (90%, 95% CI: 66.9-98.2). The hospital cutoff specificity (22.7%, 95% CI: 17.1-29.3) was significantly greater than the AADD (13.4%, 95% CI: 9.1-19.2) and standard cutoff (10.8%, 95% CI: 7.0-16.3) specificities. CONCLUSIONS: In geriatric patients presenting to the ED with suspected PE, the AADD measured in DDUs maintained sensitivity with improved specificity compared to standard cutoff. In this population, the AADD would have safely reduced imaging by 19% without missing any PEs. AADD remains a valid tool with high sensitivity and negative predictive value in ruling out PE in geriatric patients.

The Role of Thromboelastography in Identifying Coagulopathy Among Geriatric Traumatic Brain Injury Patients.

Background The geriatric population has the highest incidence of head injury, and those who are anticoagulated have an increased risk of traumatic intracranial hemorrhage (ICH). The availability of viscoelastic coagulation studies has coincided with the development of many anticoagulation reversal agents. In this study, our objective was to assess whether the thromboelastography (TEG) assay affected clinical decision-making regarding reversal agent administration among geriatric patients with ICH caused by blunt head trauma. Methodology We prospectively screened adults aged 65 and older with head trauma presenting to the emergency departments of two level-one trauma centers. International Classification of Diseases, Tenth Revision codes S00-09 were used to identify the diagnosis of head injury. Patients with CT head imaging positive for acute ICH were included. Each patient was assessed for home use of antiplatelet or anticoagulant medications, as well as in-hospital use of any reversal agents. Reversal agent administration and mortality were compared between patients who received TEG and those who did not. Results A total of 680 patients had acute ICH on head CT, and 324 (48%) patients received TEG. More patients screened with TEG were transfused platelets (30.2% vs. 10.7%, p < 0.001). This remained significant for patients taking anticoagulants, antiplatelets, or neither. There were no differences in the administration of other reversal agents (prothrombin complex concentrate or fresh frozen plasma) or mortality whether or not TEG was performed. Conclusions Patients who had TEG performed were more likely to receive platelet reversal agents, regardless of antiplatelet medication usage. Among elderly adults with ICH, TEG is a rapid screening test that may help identify patients with platelet function abnormalities requiring reversal.

Pelvic Exam Laws in the United States: A Systematic Review.

Laws regulating patient care are an essential component of protecting patients and doctors alike. No studies have previously examined what laws exist regarding pelvic examinations in the United States (US). This study systematically reviews and compares regulation and legislation of pelvic examinations in the U.S. and provides a comprehensive resource to educate clinicians, patients, and lawmakers. Each of the fifty States in the U.S. was included. The primary outcome was existence of any pelvic or rectal exam laws. Data was obtained for the type of examination defined within the law, exceptions to the law, to whom the law applied to, the type of consent required, and to whom the consent applied to. Laws were identified from each of the individual state legislative websites. All sections of each law pertaining to pelvic examination were reviewed and organized by state. Descriptive statistics were performed for each of the variables, including frequencies of each amongst the fifty states. State regulation for pelvic examinations varied from no law or regulation to laws pertaining to pelvic, rectal, prostate, and breast examination performed in any context. As of November 22, 2022, there are twenty states (40%) with pelvic examination laws applying to anesthetized or unconscious patients. Thirteen additional states (26%) have proposed pelvic exam laws. Seventeen states (34%) do not have any laws regarding pelvic examinations. Regulation of pelvic examinations has become an increasingly important issue over the past few years in response to growing concerns of patient autonomy and the ethical issues raised by such sensitive examinations. While pelvic examination laws that balance protection for patient autonomy and the needs of caregivers and educators exist in much of the U.S., more work needs to continue in consultation with physicians and health care providers to ensure that all states have reasonable laws protecting the autonomy of patients while also maintaining quality of care.