The American journal of emergency medicine
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Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center. ⋯ After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.
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Comparative Study
Which is better and useful modality of X-ray for diagnosis of pneumothorax at emergency setting: Conventional or invert-grayscale?
Why is this interesting?
Digital radiology systems (PACS) allow point-of-care enhancement and adjustment of x-ray images. 'Inverted grayscale' viewing has been advocated as a way to improve the ability to detect small pneumothoraces on posterior-anterior chest x-rays (CXR).
This case-control cross-over study challenges this practice.
What did they do?
The researchers used CXRs of 106 adult patients with a known spontaneous pneumothorax and 162 matched-controls without pneumothorax, but who had presented with pneumothorax-consistent symptoms.
Using a senior radiologist as the gold standard diagnostician, two groups of five emergency physicians were then allocated to identify the presence of a pneumothorax in all 268 CXRs – one group using inverted grayscale and the other the conventional digital view.
To ensure the groups were comparable, the researchers also had each review a random selection of both inverted and conventional images, and compared how the group diagnostic sensitivities correlated.
Bottom-line:
Surprisingly, the sensitivity of pneumothorax detection was higher for conventional imaging than when using inverted grayscale (91.7% vs 84.5%). Specificity was comparable.
Be smart…
Although the researchers showed the inferiority of isolated inverted-grayscale imaging compared to conventional, it is a technique almost always used alongside first viewing a CXR with conventional contrast. Thus even if inferior, it is unlikely to undermine the diagnostic sensitivity of standard CXR reporting.
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Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life-threatening injuries. ⋯ While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for patients with specific injury patterns.
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Pancreatitis with normal lipase and amylase level is a rare phenomenon. This is especially true in patient with end-stage renal disease as lipase and amylase are renally excreted. Literature review reveals previous case report of pancreatitis with normal lipase and amylase level, however, none of them occurred in the setting of end-stage renal disease. ⋯ However, radiological work up was consistent with pancreatitis. This case report highlight the importance of taking the overall clinical picture rather than laboratory work up to rule in or rule out the diagnosis of pancreatitis. Furthermore, this should also serve an important reminder for clinicians to further investigate where clinical suspicion for pancreatitis is high.
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Emergency Department (ED) visits for injury often precede hospital admissions in older adults, but risk factors for these admissions are poorly characterized. We sought to determine the incidence and risk factors for hospitalization shortly following discharge home from an ED visit for traumatic injury in older adults. We hypothesized higher risk for admission in those with increased age, discharged home after falls, with increased comorbidity burden, and who live in poor neighborhoods. ⋯ Among older adults treated and discharged from the ED for an injury, those who have high comorbidity burdens, have abdominal or orthopedic injuries, and live in poor neighborhoods are at increased risk of hospitalization within 9 or 30days of ED discharge.