J Emerg Med
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Multicenter Study Clinical Trial
Use of spiral computed tomography contrast angiography and ultrasonography to exclude the diagnosis of pulmonary embolism in the emergency department.
Spiral computed tomography (CT) contrast angiography is a promising imaging modality for the diagnosis of pulmonary embolism but the negative predictive value of this test remains controversial. We performed a multi-center prospective cohort study to determine the safety of relying on a negative spiral CT contrast angiography scan to exclude pulmonary embolism. Patients presenting to the Emergency Departments of three tertiary care institutions with clinically suspected pulmonary embolism were potentially eligible for the study. ⋯ Sixty-seven patients were confirmed to have pulmonary embolism and an additional 15 patients with negative CT scans had proximal deep vein thrombosis (DVT) on ultrasound for a total prevalence of venous thromboembolism of 82/489 (16.8%). Two of 409 patients who had pulmonary embolism excluded in the initial evaluation phase developed proximal venous thromboembolism (0.5%; 95% CI 0% to 1.8%) in the 3-month follow-up period. These findings suggest that the combination of a negative spiral CT contrast angiography scan and normal venous ultrasound imaging safely excludes the diagnosis of pulmonary embolism in the Emergency Department setting.
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Early intubation is standard for treating severe traumatic brain injury (TBI). Aeromedical crews and select paramedic agencies use rapid sequence intubation (RSI) to facilitate intubation after TBI, with Glasgow Coma Scale (GCS) score commonly used as a screening tool. To explore the association between paramedic GCS and outcome in patients with TBI undergoing prehospital RSI, paramedics prospectively enrolled adult major trauma victims with GCS 3-8 and clinical suspicion for head trauma to undergo succinylcholine-assisted intubation as part of the San Diego Paramedic RSI Trial. ⋯ In conclusion, paramedics seem to accurately calculate GCS values before prehospital RSI. Although a relationship between paramedic GCS and outcome exists, the ability to predict the severity of injury, airway-related complications, ICU length of stay, and overall survival is limited using this single variable. Other factors should be considered to screen TBI patients for prehospital RSI.
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Patients presenting with hypotension may be evaluated with a FAST (Focused Abdominal Sonography for Trauma) examination as recent literature has suggested its utility in the unstable patient. Those who are found to have intraperitoneal fluid on the FAST examination may have solid organ injury from unknown trauma, ruptured abdominal aortic aneurysm (AAA), hemorrhaging ovarian cyst, ruptured ectopic pregnancy, or other disease process responsible for intra-periteal blood. However, because ultrasound does not assist in fluid identification, it is possible that the fluid present is not blood, but ascites. ⋯ This case series illustrates the utility of an ultrasound guided, emergent diagnostic paracentesis in the management of unstable patients found to have a positive FAST examination. Six unstable patients were evaluated with the FAST examination and found to have large quantities of intraperitoneal fluid. In each case the fluid was sampled and proposed management changed due to fluid identification.
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Case Reports
Clinical decision rules and cervical spine injury in an elderly patient: a word of caution.
We report a case of a clinically significant cervical spine fracture in an elderly patient without midline cervical tenderness. Application of the NEXUS rule by the treating physicians ruled out the need for radiography. However, knowledge of the Canadian C-spine rule and clinical judgment prompted obtaining a three-view trauma series of the cervical spine and, when the patient's pain increased, a computed tomography scan of the cervical spine. ⋯ In review of the case it was recognized that application of the NEXUS rule for this patient was problematic regarding the assessment of mental status. Specifically, the treating physicians did not strictly adhere to the detailed explanations attached to the NEXUS criteria regarding mental status. Clinicians may wish to preferentially apply the Canadian rule for patients over the age of 64 years.
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Comparative Study
Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm.
This study assesses the accuracy of Emergency Medicine (EM) residents in detecting the size and presence of abdominal aortic aneurysms (AAAs) using EM ultrasound (EUS) compared to radiology measurement (RAD) by computed tomography (CT) scan, magnetic resonance imaging (MRI), angiography, or operative findings. There were 238 aortic EUS performed from 1999-2000; 36 were positive for AAA. The EUS finding of "AAA" had a sensitivity of 0.94 (0.86-1.0 95% confidence interval [CI]) and specificity of 1 (0.98-1.0 95% CI). ⋯ The mean absolute difference between EUS and RAD diameters was 4.4 mm (95% CI 3.7-5.5 mm). Regression of EUS on RAD diameters is strongly correlated, with R(2)=0.92. EM residents with appropriate training can accurately determine the presence of AAA as well as the maximal aortic diameter.