The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.

BACKGROUND: Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care. METHODS: A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated. RESULTS: A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care. CONCLUSION: Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Exogenous Peptide Injection Causing Medical Thigh Compartment Syndrome.

BACKGROUND: Acute compartment syndrome can be caused by any condition that increases the pressure of an intracompartmental muscular space, resulting in ischemia, which is a limb-threatening emergency. This case report is the first known documented example of an exogenously injected peptide causing compartment syndrome. The use of natural supplements and holistic therapies is on the rise, specifically, peptide injections. It is important to obtain the history of use and routes of administration of these substances. CASE REPORT: We present a case of a 43-year-old man who presented to the Emergency Department with worsening thigh pain. The patient had injected a "peptide cocktail" into his thigh 3 days prior. Physical examination revealed trace pitting edema of the left leg with moderate muscle spasm and tenderness of the medial aspect of the distal thigh with associated numbness along the medial aspect of the knee. Point-of-care ultrasound detected intramuscular edema and free fluid in the leg. He was found to have acute compartment syndrome of the thigh secondary to the peptide cocktail injection, causing a large hematoma posterior to the adductor magnus. The patient required fasciotomy and hematoma evacuation. He ultimately left against medical advice during his hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In an age when many patients look for supplements to aid with weight loss and muscle growth, it is essential to be aware of peptide injection therapies and the potential complication of compartment syndrome.

Sudden Decompensation of Patients Admitted to Non-ICU Settings Within 24 h of Emergency Department Admission.

BACKGROUND: Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics. METHODS: This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not. RESULTS: Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p = 0.023) and dyspnea (70.6% vs 29.4%, p = 0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p = 0.010) or hypertension (9.1% vs 0%, p = 0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p = 0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p = 0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found. CONCLUSIONS: Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.

Comparing rates of skull fractures in female versus male geriatric patients who sustain head injuries.

BACKGROUND: Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. This study aims to evaluate the role of sex in the risk of skull fracture in patients over the age of 65. METHODS: A prospective cohort study was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents. Over a year-long period, consecutive patients aged 65 years and older who presented with blunt head injury were included. Patients who did not receive head CT imaging were excluded. The primary outcome was rate of skull fracture due to the acute trauma, compared by sex. Additional factors examined included patient race/ethnicity and mechanism of injury. RESULTS: Among 5402 patients enrolled, 3010 (56%) were female and 2392 (44%) were male. 4612 (85%) of the head injuries sustained were due to falls, and 4536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2-2.1, p = 0.002). This trend was also seen across race/ethnicity and mechanism of injury. CONCLUSIONS: Older males were found to have a higher rate of skull fractures compared to females after sustaining blunt head trauma, mostly due to falls.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma.

BACKGROUND: Although clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. OBJECTIVE: This study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. METHODS: This prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. RESULTS: We enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67-13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67-13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15-12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24-1.99), alcohol use (OR 1.62; 95% CI 1.25-2.09), antiplatelet use (OR 1.84; 95% CI 1.46-2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54-4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. CONCLUSIONS: Although ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

Age adjusted D-dimer cutoffs for pulmonary embolism in a geriatric population utilizing a D-dimer unit assay.

BACKGROUND: Age adjusted serum d-dimer (AADD) with clinical decision rules have been utilized to rule out pulmonary embolism (PE) in low-risk patients; however, its use in the geriatric population has been questioned and the use of d-dimer unit (DDU) assay is uncommon. OBJECTIVE: The present study aims to compare the test characteristics of the AADD (age × 5) measured in DDU with the standard cutoff (DDU < 250) and study hospital laboratory's d-dimer cutoff (DDU < 600) in geriatric patients presenting with suspected PE. METHODS: This retrospective study enrolled patients ≥65 years old with suspected PE and d-dimer performed between January 1, 2019 and December 31, 2019 who presented to the emergency department (ED). Charts were reviewed for CTA chest and ventilation perfusion imaging results for PE. Diagnostic parameters for each cutoff were calculated for the primary outcome. RESULTS: 510 patients were included, 20 with PE. There was no significant difference between the sensitivities of AADD (100%, 95% CI: 80-100), standard cutoff (100%, 95% CI: 80-100), and hospital cutoff (90%, 95% CI: 66.9-98.2). The hospital cutoff specificity (22.7%, 95% CI: 17.1-29.3) was significantly greater than the AADD (13.4%, 95% CI: 9.1-19.2) and standard cutoff (10.8%, 95% CI: 7.0-16.3) specificities. CONCLUSIONS: In geriatric patients presenting to the ED with suspected PE, the AADD measured in DDUs maintained sensitivity with improved specificity compared to standard cutoff. In this population, the AADD would have safely reduced imaging by 19% without missing any PEs. AADD remains a valid tool with high sensitivity and negative predictive value in ruling out PE in geriatric patients.

Time from hospital presentation to head imaging in White, Black, and Hispanic geriatric trauma patients.

BACKGROUND: Health care disparities have been shown to negatively affect non-White people sustaining traumas, leading to increased morbidity and mortality. One possible explanation could be delays in emergent medical care. This study aims to assess if a disparity between races exists amongst acutely head-injured geriatric patients, as evidenced by the time it takes from emergency department (ED) presentation to performance of head computerized tomography (CT) imaging. METHODS: A prospective cohort study was conducted from August 15, 2019 to August 14, 2020 at the two trauma centers in a south Florida county covering 1.5 million residents. Patients aged ≥ 65 years who sustained a head injury were identified daily. Patients who had a head injury >24 h prior, sustained penetrating trauma, or were transferred from another hospital were excluded. The primary outcome was time measured between ED presentation and CT head performance. Patients were grouped by race as selected from White, Black, Hispanic, and other. Comparisons were made using ANOVA analysis. RESULTS: 4878 patients were included. 90% were White. The mean times to CT head were 90.3 min for White patients, 98.1 min for Black patients, and 86.6 min for Hispanic patients. There was a significant difference comparing time to CT between the three groups (F = 2.892, p = 0.034). Comparing each group to a combined others, there were no significant differences for White vs non-White (90.3 vs 91.3, F = 0.154, p = 0.695) or Hispanic vs non-Hispanic (86.6 vs 90.5, F = 0.918, p = 0.338); however Black vs non-Black (98.1 vs 89.9, F = 4.828, p = 0.028) was significant. CONCLUSIONS: Geriatric Black patients who sustained head trauma were found to have a longer time from ED presentation to performance of head CT than their non-Black counterparts.

Pelvic Exam Laws in the United States: A Systematic Review.

Laws regulating patient care are an essential component of protecting patients and doctors alike. No studies have previously examined what laws exist regarding pelvic examinations in the United States (US). This study systematically reviews and compares regulation and legislation of pelvic examinations in the U.S. and provides a comprehensive resource to educate clinicians, patients, and lawmakers. Each of the fifty States in the U.S. was included. The primary outcome was existence of any pelvic or rectal exam laws. Data was obtained for the type of examination defined within the law, exceptions to the law, to whom the law applied to, the type of consent required, and to whom the consent applied to. Laws were identified from each of the individual state legislative websites. All sections of each law pertaining to pelvic examination were reviewed and organized by state. Descriptive statistics were performed for each of the variables, including frequencies of each amongst the fifty states. State regulation for pelvic examinations varied from no law or regulation to laws pertaining to pelvic, rectal, prostate, and breast examination performed in any context. As of November 22, 2022, there are twenty states (40%) with pelvic examination laws applying to anesthetized or unconscious patients. Thirteen additional states (26%) have proposed pelvic exam laws. Seventeen states (34%) do not have any laws regarding pelvic examinations. Regulation of pelvic examinations has become an increasingly important issue over the past few years in response to growing concerns of patient autonomy and the ethical issues raised by such sensitive examinations. While pelvic examination laws that balance protection for patient autonomy and the needs of caregivers and educators exist in much of the U.S., more work needs to continue in consultation with physicians and health care providers to ensure that all states have reasonable laws protecting the autonomy of patients while also maintaining quality of care.

Hospital ward transfer to intensive care unit as a quality marker in emergency medicine.

BACKGROUND: Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging. OBJECTIVE: To investigate the utility of tracking patients transferred to the ICU within 24h of admission from the ED as a marker of preventable errors and adverse events. METHODS: From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement. RESULTS: Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%). CONCLUSION: Tracking patients admitted to the hospital from the ED who are transferred to the ICU <24h after admission may be a valuable marker for adverse events and preventable errors in the ED.

The Integration of Electronic Medical Student Evaluations Into an Emergency Department Tracking System is Associated With Increased Quality and Quantity of Evaluations.

BACKGROUND: Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. OBJECTIVES: To determine whether electronic medical student evaluations (EMSEs) provide more evaluations and content when compared to paper shift card evaluations. METHODS: This before and after cohort study was conducted over a 2.5-year period at an academic hospital affiliated with a medical school and emergency medicine residency program. EMSEs replaced the paper shift evaluations that had previously been used halfway through the study period. A random sample of the free text comments on both paper and EMSEs were blindly judged by medical student clerkship directors for their helpfulness and usefulness. Logistic regression was used to test for any relationship between quality and quantity of words. RESULTS: A total of 135 paper evaluations for 30 students and then 570 EMSEs for 62 students were collected. An average of 4.8 (standard deviation [SD] 3.2) evaluations were completed per student using the paper version compared to 9.0 (SD 3.8) evaluations completed per student electronically (p < 0.001). There was an average of 8.8 (SD 8.5) words of free text evaluation on paper evaluations when compared to 22.5 (SD 28.4) words for EMSEs (p < 0.001). A statistically significant (p < 0.02) association between quality of an evaluation and the word count existed. CONCLUSIONS: EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.

The Florida Geriatric Head Trauma CT Clinical Decision Rule.

BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Transient Hypoglossal and Lingual Nerve Injury Following the Use of I-gel Supraglottic Airway: A Case Report.

Injury to the hypoglossal and/or lingual nerve is a rare occurrence with the use of a laryngeal mask airway (LMA) or supraglottic airway (SGA) device. There has been one prior report of a lingual and hypoglossal nerve injury with the i-gel™ SGA. We are describing the second reported hypoglossal and lingual transient nerve injury in a male patient while using an i-gel™ SGA. Although excessive cuff pressure has been cited as a possible cause, the i-gel™ does not have a cuff. This report highlights that hypoglossal nerve injury can still occur, even with the use of a cuffless LMA such as the i-gel™ SGA.

Cerebellar Infarction from a Vertebral Artery Dissection after Blunt Chest Injury: A Case Report.

Introduction: Traumatic vertebral artery dissections resulting in stroke are relatively rare occurrences, especially in the absence of classic physical examination findings. Case Report: We present the case of a 30-year-old male with chest pain following a car axle falling onto his chest while trying to change a tire. He was discharged from the emergency department after having a negative workup for thoracic injury. Six hours later, the patient returned with headache and was found to have a cerebellar stroke secondary to vertebral artery dissection. After hospitalization, the patient was discharged home without any neurological deficits. Conclusion: As they are usually asymptomatic, up to 80% of patients with blunt cerebrovascular injury will have delayed or missed diagnoses. Given the increased awareness of vascular injuries and their high morbidity, physicians should maintain a high index of suspicion for this diagnosis.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness.

Objective: Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients. Methods: This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention. Results: Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation. Conclusion: Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Repeat Fall Risk in Geriatric Patients After Fall-Induced Head Trauma.

Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.

A Simulation-based PPE orientation training curriculum for novice physicians.

Background: Personal protective equipment (PPE) is effective in preventing coronavirus disease (COVID-19) infection. Resident knowledge of proper use and effective training methods is unknown. We hypothesise that contamination decreases and knowledge increases after a formalised PPE educational session. Methods: Participants included first year interns during their residency orientation in June 2020. Before training, participants took a knowledge test, donned PPE, performed a simulated resuscitation, and doffed. A standardised simulation-based PPE training of the donning and doffing protocol was conducted, and the process repeated. Topical non-toxic highlighter tracing fluid was applied to manikins prior to each simulation. After doffing, areas of contamination, defined as discrete fluorescent areas on participants' body, was evaluated by ultraviolet light. Donning and doffing were video recorded and asynchronously rated by two emergency medicine (EM) physicians using a modified Centers for Disease Control and Prevention (CDC) protocol. The primary outcome was PPE training effectiveness defined by contamination and adherence to CDC sequence. Results: Forty-eight residents participated: 24 internal medicine, 12 general surgery, 6 EM, 3 neurology, and 3 psychiatry. Before training, 81% of residents were contaminated after doffing; 17% were contaminated after training (P<0.001). The most common contamination area was the wrist (50% pre-training vs. 10% post-training, P<0.001). Donning sequence adherence improved (52% vs. 98%, P<0.001), as did doffing (46% vs. 85%, P<0.001). Participant knowledge improved (62%-87%, P <0.001). Participant confidence (P<0.001) and preparedness (P<0.001) regarding using PPE increased with training. Conclusion: A simulation-based training improved resident knowledge and performance using PPE.