Iatrogenic pericardial defect.

Pericardial defects are uncommon, usually congenital, and frequently involve a complete absence of the pericardium. Partial pericardial defects are more likely to result in complications. Iatrogenic pericardial defects are usually partial defects and may present with cardiac strangulation. We present the case of an iatrogenic pericardial defect in an asymptomatic 20-year-old female.

Unjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation.

BACKGROUND: Early administration of tranexamic acid (TXA) has been widely implemented for the treatment of presumed hyperfibrinolysis in hemorrhagic shock. We aimed to characterize the liberal use of TXA and whether unjustified administration was associated with increased venous thrombotic events (VTEs). METHODS: We identified injured patients who received TXA between January 2016 and January 2018 by querying our Level 1 trauma center's registry. We retrospectively reviewed medical records and radiologic images to classify whether patients had a hemorrhagic injury that would have benefited from TXA (justified) or not (unjustified). RESULTS: Ninety-five patients received TXA for traumatic injuries, 42.1% were given by emergency medical services. TXA was considered unjustified in 35.8% of the patients retrospectively and in 52% of the patients when given by emergency medical services. Compared with unjustified administration, patients in the justified group were younger (47.6 versus 58.4; P = 0.02), more hypotensive in the field (systolic blood pressure: 107 ± 31 versus 137 ± 32 mm Hg; P < 0.001) and in the emergency department (systolic blood pressure: 97 ± 27 versus 128 ± 27; P < 0.001), and more tachycardic in emergency department (heart rate: 99 ± 29 versus 88 ± 19; P = 0.04). The justified group also had higher injury severity score (median 24 versus 11; P < 0.001), was transfused more often (81.7% versus 20.6%; P < 0.001), and had higher in-hospital mortality (39.3% versus 2.9%; P < 0.001), but there was no difference in the rate of VTE (8.2% versus 5.9%). CONCLUSIONS: Our results highlight a high rate of unjustified administration, especially in the prehospital setting. Hypotension and tachycardia were indications of correct use. Although we did not observe a difference in VTE rates between the groups, though, our study was underpowered to detect a difference. Cautious implementation of TXA in resuscitation protocols is encouraged in the meantime. Nonetheless, adverse events associated with unjustified TXA administration should be further evaluated.

Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study.

OBJECTIVE: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. DESIGN: Multicenter retrospective cohort study. PATIENTS/PARTICIPANTS: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. INTERVENTION: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. MAIN OUTCOME: The main outcome was difference in complications between patients treated with volar versus dorsal approach. RESULTS: At an average follow-up of 292 days, 202 patients (range, 18-84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. CONCLUSIONS: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of Emergency Lights and Sirens by Ambulances and Their Effect on Patient Outcomes and Public Safety: A Comprehensive Review of the Literature.

The benefits of emergency lights and sirens (L&S) use as warning devices by ambulances continue to be a debated topic in Emergency Medical Services (EMS). While the most widely studied aspect of L&S use has been related to their effect on ambulance response and transport times, the literature suggests minimal time savings with more questionable impact on actual patient outcomes. As L&S use has been shown to increase the risk for vehicle crashes, the secondary concern of ambulance design and safety also becomes an important aspect on potential design recommendations that could mitigate the effects of a crash on patients, EMS providers, and the general public. The least studied aspect of L&S use (and probably the most important) is their effect on patient outcomes and quality of medical care during transport. The current evidence suggests no significant improvement on patient outcomes and potential worsening to certain aspects of patient care during transport. The purpose of this review was to examine the current literature regarding ambulance L&S use and the risks they pose to EMS providers, patients, and the general public. In doing so, it will provide sound background for EMS leaders to better develop policies governing the use of L&S by ambulances and promote better research in the patient outcomes effect associated with their use. This review offers some strategies in mitigating the risks associated with L&S use, such as ways to reduce their overall use and modifying other related factors to emergency medical vehicle collisions (EMVCs). Murray B , Kue R . The use of emergency lights and sirens by ambulances and their effect on patient outcomes and public safety: a comprehensive review of the literature. Prehosp Disaster Med. 2017;32(2):209-216.