Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury.

STUDY OBJECTIVE: The Glasgow Coma Scale (GCS) score is widely used to assess patients with head injury but has been criticized for its complexity and poor interrater reliability. A 3-point Simplified Motor Score (SMS) (defined as obeys commands=2, localizes pain=1, and withdraws to pain or worse=0) was created to address these limitations. Our goal is to validate the SMS in the out-of-hospital setting, with the hypothesis that it is equivalent to the GCS score for discriminating brain injury outcomes. METHODS: This was a secondary analysis of an urban Level I trauma registry. Four outcomes and their composite were studied: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The out-of-hospital GCS score and SMS were evaluated by comparing areas under the receiver operating characteristic curve with a paired nonparametric approach. Multiple imputation was used for missing data. A clinically significant difference in areas under the receiver operating characteristic curve was defined as greater than or equal to 0.05, according to previous literature. RESULTS: We included 19,408 patients, of whom 18% were tracheally intubated, 18% had brain injuries, 8% required neurosurgical intervention, and 6% died. The difference between the area under the receiver operating characteristic curve for the out-of-hospital GCS score and SMS was 0.05 (95% confidence interval [CI] -0.01 to 0.11) for emergency tracheal intubation, 0.05 (95% CI 0 to 0.09) for brain injury, 0.04 (95% CI -0.01 to 0.09) for neurosurgical intervention, 0.08 (95% CI 0.02 to 0.15) for mortality, and 0.05 (95% CI 0 to 0.10) for the composite outcome. CONCLUSION: In this external validation, SMS was similar to the GCS score for predicting outcomes in traumatic brain injury in the out-of-hospital setting.

Echelon I interventions and triage are effective and concordant with echelon II care in combat operations.

We describe identified injuries, effectiveness of treatment, and triage categories for combat casualties at echelon 1 from April 1 to June 30, 2005 from western Iraq. A total of 133 casualties were evaluated including 12 who were killed in action and 7 who died of wounds. A medic or corpsman treated 75% of the remaining patients, 9% were treated by bystanders, 2% were seen by a physician or physician assistant, and 15% administered self-aid. Most injuries (84%) were blast related. Commonly wounded regions were the head (47%), lower extremities (40%), upper extremities (22%), and back (11%). Common interventions included dressings (37%), splints (8%), and intramuscular morphine (8%). Field triage categories at echelon I and casualty evacuation categories at echelon II were congruent. No significant injuries were missed and there were no detrimental interventions. In conclusion, combat casualties were assessed, treated, and evacuated appropriately by echelon I providers during this time frame.

Trauma scissors vs. the rescue hook, exposing a simulated patient: a pilot study.

The objective of this study was to compare the exposure times using trauma scissors vs. the rescue hook on a simulated patient. This was a prospectively randomized, parallel group comparison study with two arms. The control group used trauma scissors (15 cycles), and the intervention group used rescue hooks (15 cycles). The uniform and footwear were standardized for each cycle. Ten participants were trained on each instrument. For each cycle, four participants were randomly chosen, and the use of either instrument was randomized. Each participant was then queried about their preferences for either instrument and why. The rescue hook's mean time of exposure was 24 s with a SD of 7 s and a 95% confidence interval (CI) of 20-28 s. The trauma scissors' mean exposure time was 42 s with a SD of 5 s and a 95% CI of 39-45 s. The mean difference was 18 s, with a 95% CI of 13-23 s. On average, the rescue hook was 43% faster. Nine of 10 participants preferred the rescue hook, stating that it was faster, easier, smaller, and more durable. The rescue hook was found to be faster than trauma scissors when exposing a simulated patient, and it was the instrument preferred by the majority of participants.

ED treatment of migraine headache: factors influencing pharmacotherapeutic choices.

STUDY OBJECTIVE: To evaluate the factors that influence clinicians' choices of parenteral medications in the emergency department (ED) management of migraine headache. BACKGROUND: Migraine headache is a common problem in the United States. Many migraineurs require periodic ED management. Though a large variety of parenteral medications are used by ED clinicians in the treatment of migraine, little research has been directed to the reasons why providers use the medications they do. METHODS: This study used a self-administered questionnaire for providers from 3 geographically distinct EDs to evaluate their pharmacotherapeutic preferences in the treatment of uncomplicated migraine based on a fictitious scenario. Factors influencing medication choices were rated on a 5-point Likert scale and analyzed descriptively. Hypothetical practice patterns from the questionnaires were compared with actual practice patterns from a prior study from the same institutions. RESULTS: Eighty-three percent of surveys were returned, the majority from attending physicians (71%), as their initial drugs-of-choice providers preferred dopaminergic antiemetics (93%) and parenteral NSAIDs (22%). If initial therapy failed, opioids (40%) with nonspecific antiemetics (24%) were preferred as second-line agents. Choice of therapy was influenced (in descending order) by medication availability and its antimigraine properties, the providers' training, current departmental practice patterns, and national practice guideline recommendations. Opioid use was influenced by patients' failure to respond to ED and outpatient alternatives and the presence of contraindications/intolerances to non-opioids. When these results were compared to a prior study of actual practice patterns, a range of discordance was observed, which varied significantly by institution. CONCLUSION: Emergency clinicians report that a variety of factors influence their parenteral pharmacotherapy in the management of patients with migraine headache. The comparison of hypothetical practice patterns with actual practice patterns reveals a range of institution-specific discordance. There is discordance between providers' responses to a fictitious scenario and their previously recorded practice patterns with regional variation.

Human influenza A (H5N1): a brief review and recommendations for travelers.

Although avian influenza A (H5N1) is common in birds worldwide, it has only recently led to disease in humans. Humans who are infected with the disease (referred to as human influenza A [H5N1]) have a greater than 50% mortality rate. Currently there has not been documented sustained human-to-human transmission; however, should the virus mutate and make this possible, the world could experience an influenza pandemic. Probable risk factors for infection include slaughtering, defeathering, and butchering fowl; close contact with wild birds or caged poultry; ingestion of undercooked poultry products; direct contact with surfaces contaminated with poultry feces; and close contact with infected humans. Possible risk factors include swimming in or ingesting water contaminated with bird feces or dead birds and the use of unprocessed poultry feces as fertilizer. Clinically, early human influenza A (H5N1) resembles typical influenza illnesses, with fever and a preponderance of lower respiratory tract symptoms. Often, patients develop rapidly progressive respiratory failure and require ventilatory support. Treatment is primarily supportive care with the addition of antiviral medications. Currently, travelers to countries with both human and avian influenza A (H5N1) have a low risk of developing the disease. There are no current recommended travel restrictions. Travelers are advised to avoid contact with all birds, especially poultry; avoid surfaces contaminated with poultry feces; and avoid undercooked poultry products. The use of prophylactic antiviral medications is not recommended.

Hemotympanums secondary to spontaneous epistaxis in a 7-year-old.

Hemotympanum is a well-known physical finding most often associated with basilar skull fractures and therapeutic nasal packing. A literature review demonstrated only five cases of hemotympanum associated with spontaneous epistaxis in adults. To our knowledge, there have been no reported cases in children. We present a case of a 7-year-old child with bilateral hemotympanums secondary to spontaneous epistaxis.

Variations among emergency departments in the treatment of benign headache.

STUDY OBJECTIVE: The practice patterns of US emergency departments in the treatment of patients with isolated benign headache have been recently described. How treatment varies among EDs has not been reported. To assess institutional variability in the pharmacotherapy of patients with benign headache, we describe and analyze the practice patterns of 3 US EDs. METHODS: This health records survey included a cohort sample of consecutive adult patients aged 16 to 65 years treated with parenteral medication for isolated benign headache at 3 nonaffiliated US EDs: a large, group-model health maintenance organization, a tertiary-care academic center, and a rural community hospital. Patients who underwent a diagnostic search for intracranial pathology, who had any nonheadache secondary diagnosis, or who had coexistent trauma, fever (temperature of > or =38.0 degrees C [100.4 degrees F]), or known pregnancy were excluded from study analysis. Demographic, clinical, and pharmacotherapeutic variables were collected for each ED visit. Descriptive analyses were performed; comparisons were made with t tests. RESULTS: Of the 490 eligible patients treated during the 4-month study period, the mean age was 36.4 years, and 374 (76%) were women. During their 629 visits, 364 (58%) received a migraine diagnosis, and 258 (41%) received a nonspecific headache diagnosis. Polypharmacy was common: 515 (82%) received 2 or more medications, and 154 (25%) received 3 or more medications. Pharmacotherapy varied greatly among the EDs. Use of opioid agonists showed the widest variation (16% to 72%), although use of dihydroergotamine (5% to 16%), prochlorperazine (32% to 59%), and adjunct diphenhydramine with prochlorperazine (42% versus 88%) also varied. CONCLUSION: Great institutional variability exists among US EDs in the parenteral treatment of patients with isolated benign headache.