Sternal Morphologic Characteristics of U.S. Military Males by Computed Tomography: Implications for Intraosseous Access.

INTRODUCTION: Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear. MATERIALS AND METHODS: Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05. RESULTS: As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions. CONCLUSIONS: Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation.

Gun Violence and Firearm Injuries in West Michigan: Targeting Prevention.

INTRODUCTION: Firearm-related deaths and injuries are ongoing public health issues in the United States. We reviewed a series of gun violence- and firearm-related injuries treated at a multi-campus community healthcare system in West Michigan to better understand the demographic and clinical characteristics of these injuries. We also studied hospital charges, and payers responsible, in an effort to identify stakeholders and opportunities for community- and hospital-based prevention. METHODS: We performed a retrospective review of firearm injuries treated at Mercy Health Muskegon (MHM) between May 1, 2015 and June 30, 2019. Demographic data, injury type, Injury Severity Score (ISS), anatomic location and organ systems involved, length of stay (LOS), mortality, time of year, and ZIP code in which the injury occurred were reviewed, as were hospital charges and payers responsible. RESULTS: Of those reviewed, 307 firearm-related injuries met inclusion criteria for the study. In 69.4% of cases the injury type was attempted murder or intent to do bodily harm. Accidental and self-inflicted injuries accounted for 25% of cases. There was a statistically significant difference in the mechanism of injury between Black and White patients with a higher proportion of Black men injured due to gun violence (P < 0.001). Median ISS was 8 and the most commonly injured organ system was musculoskeletal. Median LOS was one day. Self-inflicted firearm injuries had the highest rate of mortality (50%) followed by attempted murder (7%) and accidental discharge (3.1%; P < 0.001). Median hospital charge was $8,008. In 68% of cases, Medicaid was the payer. MHM received $4.98 million dollars in reimbursement from Medicaid; however, when direct and indirect costs were taken into account, a loss of $12,648 was observed. CONCLUSION: Findings from this study reveal that young, Black men are the primary victims of gun violence-related injuries in our West Michigan service area. Hospital care of firearm-related injuries at MHM was predominantly paid for by Medicaid. Multiple stakeholders stand to benefit from funding and supporting community- and hospital-based prevention programs designed to reduce gun violence and firearm-related injuries in our service area.

Inferior Vena Cava Thrombosis, Appendicitis Mimic.

Right lower quadrant abdominal pain is a common presentation to the Emergency Department. While appendicitis is a frequently diagnosed pathology associated with this complaint, there are multiple, well-documented alternatives that must be considered. The authors present a unique case of a 20 year old active duty male who presented with 3 days of acutely worsening right lower quadrant abdominal pain, right flank pain, and anorexia. Following a detailed work-up, computed tomography and magnetic resonance imaging (MRI) demonstrated a bland thrombus within the inferior vena cava (IVC) secondary to a vascular web. This case highlights the difficulty in astutely diagnosing appendicitis utilizing clinical examination and scoring metrics. While IVC thrombosis is a rare phenomenon, it should be considered in the emergency physician's differential for right lower quadrant abdominal pain, particularly when additional nonspecific symptoms are present.