Point-of-care procalcitonin may predict the need for surgical treatment in patients with small bowel obstruction.

BACKGROUND: The early identification of patients with small bowel obstruction who require surgical treatment could potentially lead to improved patient outcomes. We evaluated the efficacy of point-of-care procalcitonin for predicting surgical treatment among patients with small bowel obstruction. METHODS: This was a prospective observational study. We measured serum procalcitonin levels in patients who presented to the emergency department and were diagnosed with small bowel obstruction from April 1, 2018 through March 31, 2019. Patients were grouped into two groups: the elevated procalcitonin and normal procalcitonin groups. Our primary outcome was surgical treatment. RESULTS: A total of 53 patients with small bowel obstruction were included in the study, and 11 patients (20.8%) were treated operatively. Baseline characteristics were similar, except for age, between the elevated procalcitonin (≥0.12 ng/ml) and normal procalcitonin groups. The elevated procalcitonin level was significantly correlated with surgical treatment and hospital length of stay (p < 0.05). The sensitivity, specificity, and positive likelihood of procalcitonin for the former were 45.5%, 85.7%, and 5.0 respectively. CONCLUSION: The patients with small bowel obstruction who had elevated procalcitonin levels on presentation showed significantly higher rate of surgical treatment than those who had normal procalcitonin levels. Point-of-care procalcitonin might predict the need for surgical treatment in patients with small bowel obstruction and could be used as an additional diagnostic test. Further studies with more patients are needed to investigate the predictive value of point-of-care procalcitonin for surgical treatment.

Displaced anterior pelvic fracture on initial pelvic radiography predicts massive hemorrhage.

INTRODUCTION: Massive hemorrhage is often associated with unstable pelvic fractures with posterior ring injury. Initial pelvic radiography alone may not detect these posterior lesions. We examined whether the presence of an anterior pelvic fracture on initial pelvic radiography alone may identify patients who are at a high risk of major hemorrhage. MATERIALS AND METHODS: A total of 288 patients with pelvic fractures were admitted to the Fukui Prefectural Hospital during an 11-year period. After excluding 33 patients who were in cardiopulmonary arrest on arrival and nine with concomitant abdominal organ injuries requiring emergency laparotomy, 246 eligible patients were retrospectively reviewed. Anterior pelvic fractures were defined as displacement of the obturator ring, obturator ring with laterality, or displacement of the pubic symphysis on pelvic radiography. RESULTS: Massive hemorrhage was identified in 106 of 246 patients. Patients with massive hemorrhage had a higher frequency of anterior pelvic fractures on pelvic radiography and higher frequency of posterior pelvic fractures on computed tomography than those without massive hemorrhage. Logistic regression analysis identified displacement of the obturator ring by ≥5mm, obturator ring with laterality of ≥5mm, and displacement of the pubic symphysis by ≥4mm on pelvic radiography as predictors of massive pelvic hemorrhage. CONCLUSION: The results of the present study suggested that the presence of displaced anterior lesions of the pelvic ring on pelvic radiography alone, without the use of computed tomography during the initial treatment stage, may promptly identify patients at high risk of massive pelvic hemorrhage who require intervention for hemorrhage control.

Blunt thoracic aortic injury with small pseudoaneurysm may be managed by nonoperative treatment.

OBJECTIVE: The efficacy of nonoperative management of blunt thoracic aortic injury (BTAI) was evaluated in patients with pseudoaneurysm. METHODS: A retrospective review was done for patients with BTAI at Fukui Prefectural Hospital during a 9-year period. Charts were reviewed for age, gender, Injury Severity Score, Abbreviated Injury Scale for each body area, initial type of aortic injury, site of aortic injury, type of definitive management, complications, and outcomes. RESULTS: Eighteen patients with BTAI were treated at Fukui Prefectural Hospital. Of 18 patients with pseudoaneurysm, seven patients were hemodynamically unstable and four patients died because of associated injuries; there were no aortic-related deaths. All 14 surviving patients were followed up for an average of 40.9 months. Only two patients with pseudoaneurysm required operative management because of the progression of the pseudoaneurysm. The pseudoaneurysm/normal aortic diameter ratio of those with any intervention was higher than that of those with nonoperative management. CONCLUSIONS: BTAI with pseudoaneurysm can be managed nonoperatively, with about 10% risk of progression to require surgical repair.

Characteristics and diagnostic pitfalls of spontaneous visceral artery dissection in the emergency department.

BACKGROUND: Spontaneous visceral artery dissection (VAD) is a rare disease that mainly occurs in the superior mesenteric artery and celiac artery. However, VAD has been detected more frequently in the past several years because of the increasing use of computed tomography (CT) for the evaluation of abdominal symptoms. A prompt diagnosis and referral to a specialist should be made, because VAD occasionally causes critical bowel ischemia. However, there is no well-established management approach. We performed a retrospective analysis to evaluate the characteristics and prognoses of patients diagnosed with VAD. METHODS: We retrospectively examined data on patients who visited the Emergency Department (ED) at Fukui Prefectural Hospital, and were diagnosed with VAD using enhanced CT scanning from April 2004 to March 2015. All data were collected from the hospital's electronic medical records. We analyzed the clinical characteristics, comorbidity, risk factors, imaging findings, and treatment of patients. RESULTS: Fifty-six patients were identified (superior mesenteric artery: 40 patients, celiac artery: 16 patients). The median age of the patients was 54 years (range, 32-86 years) and 89.3% were men. The majority of the patients complained of abdominal pain (37 patients, 66%). Thirty-nine of the patients (69.6%) were hospitalized. All hospitalized patients received conservative treatment initially. Three patients received endovascular therapy, and 2 patients received surgery. No fatal cases were observed. Twenty-eight patients presented with ED at their initial visit, and 8 cases (29%) were undiagnosed on their initial visit by emergency physicians, though enhanced CT scans were obtained. CONCLUSION: Patients with VAD often present with sudden onset abdominal pain. Most patients were managed successfully with conservative treatment. No fatal cases were observed; however, some cases were missed, even with an enhanced CT scan. It is necessary to include VAD among the differential diagnoses of acute abdominal pain. Patients with VAD should be referred to a specialist, because this disease occasionally causes critical bowel ischemia, necessitating surgical intervention.

Absence of calvarial fracture could predict the need for tracheostomy in traumatic brain injury.

AIM: Tracheostomy is a common procedure for intubated patients with traumatic brain injury (TBI) in the intensive care unit (ICU) but optimal timing and the predictors of tracheostomy are still unclear. The aim of our study was to explore whether the traumatic variables of head injury predict the need for tracheostomy in intubated TBI patients. METHODS: A single-center, retrospective observational study including a series of TBI patients admitted to Fukui Prefectural Hospital from April 1, 2004 to March 31, 2020 was carried out. Our primary outcome was tracheostomy. Patients with TBI who were intubated and admitted into the ICU within 24 h after injury were enrolled. Exclusion criteria were age less than 18 years, pregnancy, mortality within 24 h, post-cardiac arrest syndrome, and patients for whom life-sustaining interventions were withheld. Radiologic images were also reviewed and the morphology of the head injury was categorized. RESULTS: Seventy-six patients were included. Forty-six patients (60.5%) underwent tracheostomy and 30 patients (39.5%) were successfully extubated. Calvarial fracture (odds ratio [OR] 0.34; 95% confidence interval [CI], 0.13-0.88; P = 0.03), Injury Severity Score (OR 1.07; 95% CI, 1.00-1.15; P = 0.04), and Glasgow Comas Scale score (OR 0.84; 95% CI, 0.73-0.96) were statistically significant in the univariable analysis. Multivariate logistic regression identified calvarial fracture as an independent predictor for tracheostomy. The model involving calvarial fracture, Injury Severity Score ≥16, and Glasgow Coma Scale score ≤8 showed the area under the receiver operating characteristic curve for the model was 0.737 (95% CI, 0.629-0.846). CONCLUSIONS: The absence of calvarial fracture could predict the necessity for tracheostomy in intubated TBI patients when combined with other factors. Further prospective randomized trials are necessary to confirm the findings.

Time in Collars and Collar-Related Complications in Older Patients.

BACKGROUND: Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours. METHODS: We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers. RESULTS: A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16-5.39; P = 0.02). CONCLUSIONS: Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.

The effects of flipped learning for bystander cardiopulmonary resuscitation on undergraduate medical students.

OBJECTIVES: To compare bystander cardiopulmonary resuscitation skills retention between conventional learning and flipped learning for first-year medical students. METHODS: A post-test only control group design. A total of 108 participants were randomly assigned to either the conventional learning or flipped learning. The primary outcome measures of time to the first chest compression and the number of total chest compressions during a 2-minute test period 6 month after the training were assessed with the Mann-Whitney U test. RESULTS: Fifty participants (92.6%) in the conventional learning group and 45 participants (83.3%) in the flipped learning group completed the study. There were no statistically significant differences 6 months after the training in the time to the first chest compression of 33.0 seconds (interquartile range, 24.0-42.0) for the conventional learning group and 31.0 seconds (interquartile range, 25.0-41.0) for the flipped learning group (U=1171.0, p=0.73) or in the number of total chest compressions of 101.5 (interquartile range, 90.8-124.0) for the conventional learning group and 104.0 (interquartile range, 91.0-121.0) for the flipped learning group (U=1083.0, p=0.75). The 95% confidence interval of the difference between means of the number of total chest compressions 6 months after the training did not exceed a clinically important difference defined a priori. CONCLUSIONS: There were no significant differences between the conventional learning group and the flipped learning group in our main outcomes. Flipped learning might be comparable to conventional learning, and seems a promising approach which requires fewer resources and enables student-centered learning without compromising the acquisition of CPR skills.

Longitudinal acquisition of endotracheal intubation skills in novice physicians.

Little is known about the acquisition of intubation skills among novice physicians during their one-year clinical training. Our primary objective was to determine the changes in the intubation skills of novice physicians between prior to the clinical training and after completion of the clinical training. We used data of a prospective longitudinal multicenter data registry developed to investigate factors associated with the improvement of intubation skills among novice physicians. The study participants included 90 postgraduate year 1 physicians in 2015-2016. We used 4 simulation scenarios based on the devices used (direct laryngoscope [DL] and Airway scope [AWS]) and difficulty of intubation (normal and difficult scenarios). As a marker of the intubation skills, we used the force applied on the maxillary incisors and the tongue with each intubation. We compared the data obtained prior to clinical training with those obtained after completion of one-year clinical training. When using DL, compared to prior, significantly less force were applied on the maxillary incisors and the tongue after clinical training in the normal scenario (28.0 N vs 19.5 N, p < 0.001, and 11.1 N vs 8.4 N, p = 0.004). Likewise, when using AWS, compared to prior, significantly less force were applied on the tongue after clinical training in the normal scenario (22.0 N vs 0 N, p < 0.001). The force on the tongue decreased after clinical training but not significant. These associations persisted in the difficult airway scenario. These findings suggest that force applied on oral structures can be quantified as a marker of intubation skills by using high-fidelity simulators, and the assessment of procedural competency is recommended for all novice physicians prior to performing intubation in the clinical setting to improve the quality of emergency care.

Comparison of the force applied on oral structures during intubation attempts by novice physicians between the Macintosh direct laryngoscope, Airway Scope and C-MAC PM: a high-fidelity simulator-based study.

OBJECTIVE: We examined whether the use of Airway Scope (AWS) and C-MAC PM (C-MAC) decreased the force applied on oral structures during intubation attempts as compared with the force applied with the use of Macintosh direct laryngoscope (DL). DESIGN: Prospective cross-over study. PARTICIPANTS: A total of 35 novice physicians participated. INTERVENTIONS: We used 6 simulation scenarios based on the difficulty of intubation and intubation devices. OUTCOME MEASURES: Our primary outcome measures were the maximum force applied on the maxillary incisors and tongue during intubation attempts, measured by a high-fidelity simulator. RESULTS: The maximum force applied on maxillary incisors was higher with the use of the C-MAC than with the DL and AWS in the normal airway scenario (DL, 26 Newton (N); AWS, 18 N; C-MAC, 52 N; p<0.01) and the difficult airway scenario (DL, 42 N; AWS, 24 N; C-MAC, 68 N; p<0.01). In contrast, the maximum force applied on the tongue was higher with the use of the DL than with the AWS and C-MAC in both airway scenarios (DL, 16 N; AWS, 1 N; C-MAC, 7 N; p<0.01 in the normal airway scenario; DL, 12 N; AWS, 4 N; C-MAC, 7 N; p<0.01 in the difficult airway scenario). CONCLUSIONS: The use of C-MAC, compared with the DL and AWS, was associated with the higher maximum force applied on maxillary incisors during intubation attempts. In contrast, the use of video laryngoscopes was associated with the lower force applied on the tongue in both airway scenarios, compared with the DL. Our study was a simulation-based study, and further research on living patients would be warranted.