Evaluation of a Portable Blood Gas Analyzer for Prehospital Triage in Carbon Monoxide Poisoning: Instrument Validation Study.

BACKGROUND: Carbon monoxide (CO) poisoning is an important cause of morbidity and mortality worldwide. Symptoms are mostly aspecific, making it hard to identify, and its diagnosis is usually made through blood gas analysis. However, the bulkiness of gas analyzers prevents them from being used at the scene of the incident, thereby leading to the unnecessary transport and admission of many patients. While multiple-wavelength pulse oximeters have been developed to discriminate carboxyhemoglobin (COHb) from oxyhemoglobin, their reliability is debatable, particularly in the hostile prehospital environment. OBJECTIVE: The main objective of this pilot study was to assess whether the Avoximeter 4000, a transportable blood gas analyzer, could be considered for prehospital triage. METHODS: This was a monocentric, prospective, pilot evaluation study. Blood samples were analyzed sequentially with 2 devices: the Avoximeter 4000 (experimental), which performs direct measurements on blood samples of about 50 µL by analyzing light absorption at 5 different wavelengths; and the ABL827 FLEX (control), which measures COHb levels through an optical system composed of a 128-wavelength spectrophotometer. The blood samples belonged to 2 different cohorts: the first (clinical cohort) was obtained in an emergency department and consisted of 68 samples drawn from patients admitted for reasons other than CO poisoning. These samples were used to determine whether the Avoximeter 4000 could properly exclude the diagnosis. The second (forensic) cohort was derived from the regional forensic center, which provided 12 samples from documented CO poisoning. RESULTS: The mean COHb level in the clinical cohort was 1.7% (SD 1.8%; median 1.2%, IQR 0.7%-1.9%) with the ABL827 FLEX versus 3.5% (SD 2.3%; median 3.1%, IQR 2.2%-4.1%) with the Avoximeter 4000. Therefore, the Avoximeter 4000 overestimated COHb levels by a mean difference of 1.8% (95% CI 1.5%-2.1%). The consistency of COHb readings by the Avoximeter 4000 was excellent, with an intraclass correlation coefficient of 0.97 (95% CI 0.93-0.99) when the same blood sample was analyzed repeatedly. Using prespecified cutoffs (5% in nonsmokers and 10% in smokers), 3 patients (4%) had high COHb levels according to the Avoximeter 4000, while their values were within the normal range according to the ABL827 FLEX. Therefore, the specificity of the Avoximeter 4000 in this cohort was 95.6% (95% CI 87%-98.6%), and the overtriage rate would have been 4.4% (95% CI 1.4%-13%). Regarding the forensic samples, 10 of 12 (83%) samples were positive with both devices, while the 2 remaining samples were negative with both devices. CONCLUSIONS: The limited difference in COHb level measurements between the Avoximeter 4000 and the control device, which erred on the side of safety, and the relatively low overtriage rate warrant further exploration of this device as a prehospital triage tool.

Intraosseous Plate Reduction and Fixation of Complex Proximal Ulnar Fractures: A Report of 2 Cases.

CASE: We describe 2 cases using a novel technique of intraosseous plating of the coronoid as a reduction tool and fixation construct for complex elbow fracture dislocations. Each patient sustained traumatic, complex injuries of the elbow and were radiographically healed at the final follow-up. CONCLUSION: Elbow fracture dislocations are complex injuries because of the interplay between primary and secondary stabilizers. This technique provides access to fracture fragments with minimal to no soft-tissue disruption and does not obstruct additional reduction or fixation of the injury.

The Dislocated Hip on CT Scan: An Argument for the Initial Pelvic Radiograph in Trauma Patients.

This study evaluated the frequency in which a hip dislocation is first diagnosed by computed tomography (CT) scan. A retrospective review was conducted of orthopaedic trauma patients presenting with hip dislocation to a Level 1 trauma center over three years. We recorded whether the patient first received pelvic radiograph (PXR) or CT scan of the pelvis, if the patient underwent closed reduction of the hip prior to CT scan, and if repeat pelvis CT scan was done. Of 83 hip dislocations, 64 patients were sent to CT scanner dislocated; 19 patients first had PXR and underwent closed reduction of the hip prior to CT scan. By obtaining a PXR, reducing the hip prior to CT, the incidence of repeat CT scan decreased from 37% to 11% (p = 0.046). By diagnosing hip dislocation, reducing prior to CT scan, repeat scans can be reduced, thus decreasing cost and radiation exposure to patients. (Journal of Surgical Orthopaedic Advances 29(1):4345, 2020).

Latino Political Attitudes: Myths and Misconceptions.

The Latino population explosion is changing the electoral calculus in American politics. But Latino voters are often misunderstood, their heterogeneity underappreciated, the importance of their religious identities overstated, and their political clout ignored because of geographic concentration. In this article, we address these widely held misconceptions.

Treatment Algorithm for Surgical Site Infections Following Extensor Mechanism Repair.

¼: Despite general agreement regarding techniques for extensor mechanism repair, there is very limited guidance in the literature for the management of surgical site infections (SSIs) that may occur after these procedures. ¼: Early or mild superficial SSIs, such as cellulitis, can be managed on an outpatient basis while monitoring for improvement, with escalated intervention if the symptoms do not resolve within 1 week. ¼: Deep SSIs should be managed more aggressively with surgical irrigation and debridement (I&D), including the knee joint, depending on the results of the aspiration, removal of all braided nonabsorbable suture (if necessary) with immediate or delayed exchange with monofilament suture, and the administration of parenteral antibiotics based on culture results and an infectious disease consult. ¼: Arthrocentesis should be performed early to monitor for the spread of infection to the joint space, and diagnosis of a septic knee joint should be immediately followed by arthroscopic or open I&D. ¼: For refractory cases (i.e., wound coverage issues or persistent infections despite multiple attempts at debridement), a consult with a plastic surgeon for consideration of a gastrocnemius flap is recommended, and surgeons should remain suspicious of the possibility of the contiguous spread of osteomyelitis.

The role of patient advocacy organizations in shaping medical research: the Pompe model.

The Pompe model is the term used by the Pompe community to describe the relationship that exists between the patient community, the medical/scientific community, and industry. The development of the Pompe model represented a new paradigm for the involvement of patients in new treatments-and also for scientists and pharmaceutical companies. It saw patients developing a sense of agency, of involvement in the process of treatment development rather than powerless recipients or (if lucky) occasional spectators. At the same time, as described below, it benefited the other partners in the process with the result that the different components of the model added up to more than the sum of their parts. However, in order for this to happen, each part had to undergo a transformation in mindset. The development of enzyme replacement therapy (ERT) for Pompe disease represented a unique set of circumstances and individuals that helped to bring about this change and, in doing so, created a model that has had far wider applications.

Does Traction Decrease the Need for Open Reduction in Femoral Shaft Fractures Treated Within 24 Hours?

This study evaluates whether preoperative skeletal traction reduces the need for open reduction in femoral shaft fractures treated with intramedullary nailing (IMN) within 24 hours. A retrospective review was conducted of femoral shaft fractures undergoing IMN within 1 day of admission. Primary outcome was an open reduction at the time of IMN. Secondary outcomes were blood loss and transfusion requirements. One hundred eighty-four patients were analyzed, 106 in the knee immobilizer group and 78 in the skeletal traction group. Skeletal traction did not reduce the need for an open reduction. The knee immobilizer group required open reduction in 13% (14/106) compared with 14% (11/78) in the skeletal traction group, which was not significant (p $=$ .89). Blood loss and transfusion rates were similar between groups. Skeletal traction does not appear to reduce the need for open reduction at the time of IMN for femoral shaft fractures treated within 1 day of admission. (Journal of Surgical Orthopaedic Advances 27(4):303-306, 2018).

Outcomes of Low-Energy Basicervical Proximal Femoral Fractures Treated with Cephalomedullary Fixation.

BACKGROUND: Basicervical peritrochanteric fractures are relatively rare, with 1.8% to 7.6% of hip fractures being identified as true basicervical fractures. The compression hip screw traditionally has been considered the "gold standard" for operative fixation of peritrochanteric fractures, with generally good results. The purpose of this study was to report the outcomes of basicervical peritrochanteric fractures of the proximal part of the femur treated with cephalomedullary nailing (CMN). METHODS: We reviewed medical records and radiographs of all patients at our institution with a peritrochanteric fracture treated with CMN from 2010 to 2012 (246 patients). Fourteen patients with a 2-part basicervical fracture were identified. Two of them died less than 6 weeks after injury and another patient did not return for follow-up. Eleven patients were included in the reported series. RESULTS: Five of the 11 patients had fracture-healing without complications. Their average tip-apex distance was 14.9 mm. The fixation failed in the remaining six patients, all of whom had a tip-apex distance of <25 mm, with an average of 17.4 mm. Four of the failures followed an anatomic reduction, and the other 2 followed a nearly anatomic reduction. CONCLUSIONS: CMN may be inadequate for fixation of 2-part basicervical fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury patterns related to ultralight aircraft crashes.

PURPOSE: Flying ultralight aircraft is a popular and growing form of recreation. However, there is considerable risk involved in this activity. This study was undertaken to catalogue the injury patterns, surgical procedures, and complications of patients involved in ultralight crashes in southwest Michigan. BASIC PROCEDURES: The trauma registry at Bronson Methodist Hospital was used to retrospectively identify all ultralight crashes between 1983 and 2006. All patients who survived to the hospital were included in the study. MAIN FINDINGS: Seventeen patients were identified, all males with a mean age of 48.5 years. Mean injury severity score was 23, with all patients sustaining multiple injuries. Mortality was 17%. Lower extremity fractures were most common, followed by head/neck/facial injuries. Orthopedic extremity procedures were most commonly performed. PRINCIPAL CONCLUSIONS: Ultralight crashes result in complex high-energy injury patterns. These patients are likely to require the resources of designated trauma centers. Increased oversight may help prevent ultralight-related injuries.

Comparison of autograft vs allograft in opening-wedge high tibial osteotomy.

Opening-wedge high tibial osteotomy (HTO) is used to treat isolated medial knee joint arthritis. A benefit of using allograft instead of autograft is avoiding a second surgical site, thereby decreasing operative time, blood loss, and pain. Our study objective was to evaluate allograft vs autograft in the failure and complication rates of HTO using the same technique and implant system (Arthrex HTO plate system, Arthrex, Inc, Naples, Fla). Seventy knees in 65 patients were evaluated. There was a 6-fold higher failure rate for the allograft group. When there was no lateral cortical breach, construct failure did not occur in 87.8% of the knees (P = .0006); with lateral cortical breach, construct failure occurred 53% of the time (P = .0006). Seventy-six and a half percent of breached cortices and 75% of failures were associated with large wedge sizes (>or=11 mm); this may suggest a role for closing-wedge osteotomy or alternative osteotomies when larger alignment corrections are needed.

Skeletal versus skin traction before definitive management of pediatric femur fractures: a comparison of patient narcotic requirements.

BACKGROUND: Pediatric patients with femoral shaft fractures are often placed in traction as a temporizing measure before definitive management. The purpose of our study was to compare narcotic use in pediatric patients with isolated femoral shaft fractures that were initially treated with skeletal traction with similar patients that were initially treated with skin traction. The hypothesis was that narcotic use would not be significantly different between the groups. METHODS: Chart review at 2 institutions was carried out to identify pediatric patients with isolated femoral shaft fractures treated with either skeletal traction or skin traction. The patients' age, weight, and the amount and duration of narcotic use were recorded. A 2-sample t test was used for the comparison. RESULTS: Fifty-one patients were treated with skin traction and 24 patients were treated with skeletal traction. Patients in the skeletal traction group used more pain medication (0.0177 mg/kg/h in traction) than those in the skin traction group (0.0137 mg/kg/h in traction), but this was not statistically significant (P=0.1031). CONCLUSIONS: The findings support our hypothesis that the amount of narcotics used between the skeletal traction group and skin traction group would not be significantly different. In using narcotic requirement as a gross measure of patient comfort while in traction, it seems there may be no benefit to the patient to have invasive skeletal traction while awaiting definitive management of their fracture. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Guide-wire exchange before insertion of intramedullary nails.

In the past, before a reamed intramedullary nail was inserted, it was mandatory to exchange the beaded-tip reaming guide wire with a smooth-tip wire. This additional step is optional in most new nail designs. Here we describe 2 cases in which not exchanging the wire led to initial wire incarceration and introduced additional steps that had to be taken before locked nailing could be completed. Intramedullary nail designs that avoid extra steps and thereby promote simplicity and reliability of insertion are potentially advantageous to both patient and surgeon. Eliminating the exchange tube and the smooth wire, however, should be approached with caution, as no time may be saved, and the procedure may be made much more difficult technically.

Skin breakdown following circumferential pelvic antishock sheeting: a case report.

Hemodynamic instability in the setting of high-energy blunt trauma is a challenging clinical scenario. Rapid provisional stabilization of the unstable pelvis is advisable because it reduces ongoing blood loss and pain by imparting bone and soft tissue stability as well as reducing pelvic volume. The use of a standard bed sheet has become a popular choice for achieving temporary stability of the pelvis through a technique that has been called circumferential pelvic antishock sheeting. Although we have found circumferential pelvic antishock sheeting to be a valuable tool in our institution, we describe a case of skin compromise that precluded complete internal fixation of a complex pelvic ring/acetabular fracture.