A challenging decision for emergency physicians: Routine repeat computed brain tomography of the brain in head trauma in infants and neonates.

BACKGROUND: Head trauma is a leading cause of death and disability. While standard treatment protocols exist for severe head trauma, no clear follow-up standards are available for mild head trauma with positive imaging findings in infants and newborns. Although routine follow-up brain computed tomography (CT) imaging is not recommended for children with moderate and mild head trauma, the necessity for follow-up imaging in infants and newborns remains uncertain. METHODS: Our study is a retrospective, observational, and descriptive study. Infants under 1 year old presenting to the emergency department with isolated head trauma were reviewed with the approval of the Ethics Committee of Ankara Etlik City Hospital. Inclusion criteria included presentation to the emergency department, undergoing more than one brain CT scan, and sustaining mild head trauma (Glasgow Coma Scale [GCS] >13). Patients with incomplete follow-up data or multiple traumas were excluded. Age, gender, mechanism of trauma, initial and follow-up brain CT findings, hospital admission, and surgical procedures were recorded and analyzed using the SPSS statistical package. RESULTS: Out of 238 screened patients, 154 were included in the study. Of these, 66.9% were male and the average age was 5.99 months. The most common presenting symptom was swelling at the trauma site, observed in 79.2% of cases. The most common mechanism of injury was falling from a height of less than 90 cm, accounting for 85.1% of cases. Pathological progression on follow-up CT was observed in 5.2% of the patients, and only 1.9% required surgical treatment. A total of 34.4% of the patients required hospitalization. Patients with parenchymal brain pathology had a higher rate of pathological progression on follow-up CT and a longer hospital stay. CONCLUSION: Follow-up CT scans in infants with mild head trauma do not alter patient outcomes except in cases with brain parenchymal pathology. Study data indicated that repeat imaging is not beneficial for isolated skull fractures. Imaging artifacts often necessitated repeated scans, contributing to increased radiation exposure. Unnecessary repeat imaging escalates radiation exposure and healthcare costs. Only a small percentage of patients exhibited progression of intracranial pathology, justifying follow-up imaging solely in the presence of brain parenchymal injury. Larger prospective studies are necessary to confirm these findings.

Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation.

OBJECTIVE: In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile. METHODS: Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded. RESULTS: A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002). CONCLUSION: It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better. CLINICAL TRIAL REGISTRATION NUMBER: NCT05343702.

Evaluating emergency department visits for spontaneous and traumatic pneumomediastinum: a retrospective analysis.

BACKGROUND: Pneumomediastinum signifies the accumulation of air within the mediastinum. This condition can develop sponta-neously or as a secondary condition due to trauma or iatrogenic causes. Although rare, it is part of a wide differential diagnosis scale due to its most common presenting symptoms: chest pain and shortness of breath. METHODS: Our study is a retrospective, observational, and cohort investigation. It included patients who presented to the emer-gency department and were diagnosed with pneumomediastinum through computed tomography. The study evaluated patients' so-ciodemographic features, methods of presentation, chest tube insertion, other surgical procedures, outcomes, and patient dispositions. The primary outcome of the study focused on the results of traumatic and spontaneous pneumomediastinum: hospital admission, the necessity for thoracostomy tube insertion, requirement for surgical procedures, and mortality. The secondary aim was to determine the relationship between other clinical features and laboratory parameters and their impact on the outcomes. RESULTS: The study comprised 67 cases. The average age of the cases was 44.89±2.41 years. Of the cases, 67.2% (n=45) were male. In terms of development, 40.3% (n=27) of cases were classified as spontaneous, and 59.7% (n=40) were post-trauma pneumomediasti-num diagnoses. Among symptoms, 50.7% (n=34) of patients experienced dyspnea, and 49.3% (n=33) presented with chest pain, while symptoms like cough, fever, nausea, vomiting, and swallowing difficulty were reported in varying proportions. Among the patients, 9.0% (n=6) had lung disease, 29.9% (n=20) had comorbidities, 3.0% (n=2) had a history of substance use, 14.9% (n=10) underwent thoracostomy tube insertion, and 20.9% (n=14) required surgical procedures. While 35.8% (n=24) of the patients were admitted to the intensive care unit, 13.4% (n=9) died. The mean total hospital stay was calculated as 8.68±1.12 days. No statistically significant relationship was found between the development of pneumomediastinum and hospital admission (p=0.507). CONCLUSION: Upon examining the causes of pneumomediastinum cases, it was observed that patients with a history of trauma required thoracostomy tube insertion and surgical intervention more frequently. However, when classified as spontaneous or trau-matic, both groups exhibited similar clinical courses and outcomes. Both groups demonstrated favorable clinical outcomes.

Untangling diagnostic confusion in internal abdominal hernias.

BACKGROUND: Internal hernias involve the herniation of intestines through mesenteric or peritoneal defects in the gastrointestinal system. Etiologically, they are generally classified as congenital or acquired. Internal hernias often present with non-specific symptoms. Despite the increased use of computed tomography (CT), discrepancies between imaging findings and diagnostic accuracy continue to pose challenges for clinicians. This study aims to compare the outcomes of patients presenting to the emergency department with abdominal pain and receiving a preliminary internal hernia diagnosis through CT, followed by laparotomy. METHODS: Our research is a retrospective, observational, and descriptive study. It includes patients presenting to the emergency department with abdominal pain, who were provisionally diagnosed with internal hernia based on CT. Patient data recorded age, gen-der, CT-identified internal hernia type, surgery, diagnoses, hospitalization status, duration of hospital stay, bowel resection, mortality, and blood parameters. The Welch classification was used to categorize internal hernia types, with eight types examined. RESULTS: Among 112 patients with a preliminary internal hernia diagnosis based on abdominal CT, the median age was 52 years. Of these, 46 were female and 66 were male. Among all patients, 87 were admitted to the hospital for observation and surgery, while 25 were discharged after emergency department. Paraduodenal hernias were the most common provisional diagnosis (48 cases). Among these patients, 45 were discharged after symptom relief and were advised for elective re-evaluation. The exact diagnosis for these pa-tients remains unknown. Post-surgery, the diagnosis of internal hernia was confirmed in 32 cases. Among them, 15 were female and 17 were male, with a median age of 52. The median hospital stay for patients diagnosed with internal hernia was 5 days. Although acquired hernias exhibited higher resection and mortality rates, no statistically significant difference was found. Thirty-five cases received dif-ferent diagnoses: 19 had brid ileus, five had volvulus, six had acute appendicitis, one had duodenal perforation, three had gynecological malignancies, and one had renal malignancy. CONCLUSION: Although internal hernias are rare, early diagnosis and treatment are very important due to the high risk of death. The study findings indicate that increased CT utilization leads to earlier diagnosis and treatment, resulting in improved prognosis for patients. This study holds one of the largest case series in the literature. It provides a novel perspective by evaluating radiologically-diagnosed cases, confirming diagnoses post-surgery, and comparing conditions that mimic internal hernias, thereby making a valuable contribution to the literature.