J Emerg Med
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Obese and overweight people have higher rates of ankle injury, particularly operative ankle fractures. The initial management of unstable ankle fractures includes closed reduction and splinting to limit soft tissue injury and articular cartilage damage until definitive operative fixation can be performed. Adequate reduction can be more difficult in the obese patient due to the weight and additional padding provided by the larger soft tissue envelope. ⋯ Obese patients have unique musculoskeletal injury profiles and special considerations in their management. The authors have found this technique useful in the management of their ankle fractures.
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Recent clinical advances with new mechanical circulatory systems have led to additional strategies in the treatment of end-stage heart failure. The third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a blood pump and a driveline (cable) that exits the patient's skin connecting the implanted pump to an externally worn controller. We report a rare case of a HeartWare LVAD driveline rewiring after accidental (presumed) transection of the driveline system. ⋯ A 67-year-old male with a medical history of ischemic cardiomyopathy status post HeartWare LVAD implantation presented to the emergency department (ED) after acute LVAD failure. On the morning of presentation, he attempted to cut the paper tape off of his adult diaper with scissors and accidentally (presumed) and unwitnessed severed the driveline system. The patient immediately went into cardiac arrest and was transported to a regional medical center. On arrival, he exhibited no appreciable vital signs and was subsequently intubated, vascular access was placed, and inotropic support initiated. The emergency physician individually stripped and reconnected the color-coded driveline wires using multiple hemostats, electrical tape, and cardboard, which resulted in regeneration of positive LVAD flows. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VAD patients will present in extremis typically to the ED with manifestations of pump dysfunction ranging from diminished flows needing fluid management or pump adjustments to full pump failure manifesting as cardiogenic shock, needing rapid resuscitation and transfer to a cardiothoracic surgical unit with on-site VAD-perfusion specialists.
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Acute coagulopathy associated with trauma has been recognized for decades and is a constituent of the "triad of death" together with hypothermia and acidosis. ⋯ Acute coagulopathy is present on admission to the ED and is associated with injury severity and significantly higher mortality.
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Simulation use for training residents has become an expectation in emergency medicine in order to improve the educational dimensions of cognitive knowledge, critical thinking, psychomotor skills, and clinical performance. ⋯ SimWars gives educators an opportunity to watch the decision-making process of the learners as they manage simulated complex scenarios in a cooperative competitive environment.
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There are few studies researching the effect of fresh frozen plasma (FFP) transfusion on international normalized ratio (INR) in patients with coagulation abnormality. ⋯ A significant improvement in INR was observed in patients with higher pretransfusion INR. While determining FFP dose for patients admitted to the ED due to coagulation defect, pretransfusion INR value should be taken into account.